BUSINESS YEAR,STATE CODE,ISSUER ID,SOURCE NAME,VERSION NUMBER,IMPORT DATE,STANDARD COMPONENT ID,PLAN ID,BENEFIT NAME,IS EHB,IS STATE MANDATE,IS COVERED,QUANTITY LIMIT ON SVC,LIMIT QUANTITY,LIMIT UNIT,MINIMUM STAY,EXCLUSIONS,EXPLANATION,EHB VAR REASON,IS SUBJECTED TO DED TIER 1,IS SUBJECTED TO DED TIER 2,IS EXCLUDED FROM INN MOOP,IS EXCLUDED FROM OON MOOP
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0010006,10345NY0010006-01,Routine Dental Services (Adult),,,,,,,,,"X-Rays, Fillings, and Simple Extractions. $1,000 plan year benefit maximum.",Not EHB,,,Yes,Yes
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0010006,10345NY0010006-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (Cleanings, flouride & sealants)",,,,No,Yes
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0010006,10345NY0010006-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,Yes
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0010006,10345NY0010006-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,Yes
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0010006,10345NY0010006-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,Yes
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0010006,10345NY0010006-01,Basic Dental Care - Adult,,,,,,,,,"Cleanings and Exams. $1,000 plan year benefit maximum. TMJ services covered with separate $300 lifetime maximum and 12 month waiting period.",Not EHB,,,Yes,Yes
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0010006,10345NY0010006-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0010006,10345NY0010006-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0010006,10345NY0010006-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0030007,10345NY0030007-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0030007,10345NY0030007-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (Cleanings, flouride & sealants)",,,,No,Yes
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0030007,10345NY0030007-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,Yes
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0030007,10345NY0030007-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,Yes
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0030007,10345NY0030007-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,Yes
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0030007,10345NY0030007-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0030007,10345NY0030007-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0030007,10345NY0030007-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0030007,10345NY0030007-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0030009,10345NY0030009-01,Routine Dental Services (Adult),,,,,,,,,"X-rays, Fillings, and Simple Extractions.",Not EHB,,,Yes,Yes
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0030009,10345NY0030009-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, flouride & sealants)",,,,No,Yes
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0030009,10345NY0030009-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,Yes
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0030009,10345NY0030009-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,Yes
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0030009,10345NY0030009-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,Yes
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0030009,10345NY0030009-01,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams.,Not EHB,,,Yes,Yes
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0030009,10345NY0030009-01,Orthodontia - Adult,,,,,,,,,Orthodontics,Not EHB,,,Yes,Yes
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0030009,10345NY0030009-01,Major Dental Care - Adult,,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Not EHB,,,Yes,Yes
2019,NY,10345,SERFF,1,3/4/2019 0:00,10345NY0030009,10345NY0030009-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-01,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010001,11177NY0010001-03,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-01,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-02,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0010002,11177NY0010002-03,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Abortion for Which Public Funding is Prohibited,,,,,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020001,11177NY0020001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Abortion for Which Public Funding is Prohibited,,,,,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020002,11177NY0020002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Abortion for Which Public Funding is Prohibited,,,,,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020003,11177NY0020003-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Abortion for Which Public Funding is Prohibited,,,,,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020004,11177NY0020004-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Abortion for Which Public Funding is Prohibited,,,,,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020005,11177NY0020005-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Abortion for Which Public Funding is Prohibited,,,,,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020006,11177NY0020006-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Abortion for Which Public Funding is Prohibited,,,,,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020007,11177NY0020007-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Abortion for Which Public Funding is Prohibited,,,,,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0020008,11177NY0020008-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-01,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-02,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030001,11177NY0030001-03,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-01,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-02,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-04,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-05,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030002,11177NY0030002-06,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-01,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-02,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030003,11177NY0030003-03,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-01,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-02,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0030004,11177NY0030004-03,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-01,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-02,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-03,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-04,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-05,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040001,11177NY0040001-06,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-01,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-02,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-03,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-04,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-05,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0040002,11177NY0040002-06,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050001,11177NY0050001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050002,11177NY0050002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050003,11177NY0050003-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050004,11177NY0050004-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050005,11177NY0050005-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050006,11177NY0050006-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050007,11177NY0050007-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0050008,11177NY0050008-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-01,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-03,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-04,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-05,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070001,11177NY0070001-06,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-01,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-02,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-03,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-04,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-05,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0070002,11177NY0070002-06,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-01,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-02,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080001,11177NY0080001-03,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-01,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-02,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0080002,11177NY0080002-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090001,11177NY0090001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090002,11177NY0090002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090003,11177NY0090003-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090004,11177NY0090004-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090005,11177NY0090005-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090006,11177NY0090006-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090007,11177NY0090007-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0090008,11177NY0090008-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-01,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-02,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110001,11177NY0110001-03,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-01,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-02,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0110002,11177NY0110002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120001,11177NY0120001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120002,11177NY0120002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120003,11177NY0120003-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120004,11177NY0120004-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120005,11177NY0120005-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120006,11177NY0120006-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120007,11177NY0120007-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Routine Dental Services (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Private-Duty Nursing,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Cosmetic Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Routine Foot Care,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Weight Loss Programs,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Basic Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Orthodontia - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Cochlear Implants,,,,,1,Item(s) per Year,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Diabetic Equipment & Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Inpatient Rehabilitation Services,,,,,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Contact Lenses for Children,,,,,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0120008,11177NY0120008-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0140001,11177NY0140001-01,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-01,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-02,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160001,11177NY0160001-03,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-01,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-02,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0160002,11177NY0160002-03,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-01,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170001,11177NY0170001-03,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-01,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-02,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0170002,11177NY0170002-03,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-01,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-02,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180001,11177NY0180001-03,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-01,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-02,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0180002,11177NY0180002-03,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-01,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-02,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210001,11177NY0210001-03,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-02,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0210002,11177NY0210002-03,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-01,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-02,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220001,11177NY0220001-03,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-01,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-02,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0220002,11177NY0220002-03,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-01,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-02,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-04,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-05,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230001,11177NY0230001-06,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-01,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-02,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-03,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-04,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-05,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0230002,11177NY0230002-06,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-01,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-02,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-03,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-05,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240001,11177NY0240001-06,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-01,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-02,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-03,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-04,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-05,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0240002,11177NY0240002-06,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-01,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-02,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260001,11177NY0260001-03,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-01,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-02,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Basic Dental Care - Adult,,,,,,,,,Cleanings and Exams. No waiting period. One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Major Dental Care - Adult,,,,,,,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Accidental Dental,Yes,,,,,,,,Coverage Depends on Adult Benefit Design (also covered under medical plans),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Cochlear Implants,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Contact Lenses for Children,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Inpatient Rehabilitation Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Design,,,,,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). In addition to pediatric dental and dision our Non-Standard plans include adult dental and vision coverage. HSA plans are also available for members seeking to maximize their care with a Health Savings Account.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Frames & Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0260002,11177NY0260002-03,Contact Lenses,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-02,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-03,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-04,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-05,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270001,11177NY0270001-06,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-01,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-02,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270002,11177NY0270002-03,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-01,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-02,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Specialist Visit,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Routine Dental Services (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Private-Duty Nursing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Routine Eye Exam (Adult),,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Emergency Room Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Bariatric Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Cosmetic Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Prenatal and Postnatal Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Generic Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Specialty Drugs,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Chiropractic Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Durable Medical Equipment,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Routine Foot Care,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Acupuncture,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Weight Loss Programs,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Well Baby Visits and Care,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Orthodontia - Child,Yes,,,,,,,,Orthodontics,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Basic Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Orthodontia - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Major Dental Care - Adult,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Transplant,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Accidental Dental,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Dialysis,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Allergy Testing,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Chemotherapy,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Radiation,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Diabetes Education,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Reconstructive Surgery,Yes,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,11177,SERFF,1,3/4/2019 0:00,11177NY0270003,11177NY0270003-03,Design,,,,No,,,,,"Coverage with no cost sharing for most preventive services (annual physicals, well visits, select contraception). Our Standard plans include pediatric dental and vision coverage.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170015,18029NY1170015-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170016,18029NY1170016-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170017,18029NY1170017-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170018,18029NY1170018-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170019,18029NY1170019-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170020,18029NY1170020-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170021,18029NY1170021-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170022,18029NY1170022-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170033,18029NY1170033-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170035,18029NY1170035-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170036,18029NY1170036-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170037,18029NY1170037-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170040,18029NY1170040-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170043,18029NY1170043-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170045,18029NY1170045-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170046,18029NY1170046-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170065,18029NY1170065-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170066,18029NY1170066-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170067,18029NY1170067-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170068,18029NY1170068-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170069,18029NY1170069-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170070,18029NY1170070-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170071,18029NY1170071-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170072,18029NY1170072-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170097,18029NY1170097-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170098,18029NY1170098-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170099,18029NY1170099-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170100,18029NY1170100-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170101,18029NY1170101-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170102,18029NY1170102-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170103,18029NY1170103-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1170104,18029NY1170104-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180001,18029NY1180001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180002,18029NY1180002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180009,18029NY1180009-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-02,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180021,18029NY1180021-03,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-02,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180022,18029NY1180022-03,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  This plan does not require referrals to access care.  The deductible is aggregated.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  This plan does not require referrals to access care.  The deductible is aggregated.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-02,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  This plan does not require referrals to access care.  The deductible is aggregated.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180077,18029NY1180077-03,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  This plan does not require referrals to access care.  The deductible is aggregated.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  This plan does not require referrals to access care.  The deductible is aggregated.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-02,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  This plan does not require referrals to access care.  The deductible is aggregated.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1180078,18029NY1180078-03,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200033,18029NY1200033-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200035,18029NY1200035-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200036,18029NY1200036-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200037,18029NY1200037-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200040,18029NY1200040-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200043,18029NY1200043-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200045,18029NY1200045-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200046,18029NY1200046-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200081,18029NY1200081-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200083,18029NY1200083-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200084,18029NY1200084-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200085,18029NY1200085-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200088,18029NY1200088-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200091,18029NY1200091-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200093,18029NY1200093-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200094,18029NY1200094-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200129,18029NY1200129-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200130,18029NY1200130-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200131,18029NY1200131-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200132,18029NY1200132-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200133,18029NY1200133-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200134,18029NY1200134-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200135,18029NY1200135-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200136,18029NY1200136-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200137,18029NY1200137-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200138,18029NY1200138-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200139,18029NY1200139-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200140,18029NY1200140-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200141,18029NY1200141-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200142,18029NY1200142-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200143,18029NY1200143-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200144,18029NY1200144-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200177,18029NY1200177-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200178,18029NY1200178-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200179,18029NY1200179-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200180,18029NY1200180-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200181,18029NY1200181-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200182,18029NY1200182-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200183,18029NY1200183-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200184,18029NY1200184-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Wellness Benefit,,,,,,,,,"Subscriber and covered spouse are both eligible to receive a 50% discount (up to $50 each) on the purchase of an approved wireless activity tracker.  Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200185,18029NY1200185-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Wellness Benefit,,,,,,,,,"Subscriber and covered spouse are both eligible to receive a 50% discount (up to $50 each) on the purchase of an approved wireless activity tracker.  Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200186,18029NY1200186-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Wellness Benefit,,,,,,,,,"Subscriber and covered spouse are both eligible to receive a 50% discount (up to $50 each) on the purchase of an approved wireless activity tracker.  Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200187,18029NY1200187-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Wellness Benefit,,,,,,,,,"Subscriber and covered spouse are both eligible to receive a 50% discount (up to $50 each) on the purchase of an approved wireless activity tracker.  Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200188,18029NY1200188-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Wellness Benefit,,,,,,,,,"Subscriber and covered spouse are both eligible to receive a 50% discount (up to $50 each) on the purchase of an approved wireless activity tracker.  Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200189,18029NY1200189-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Wellness Benefit,,,,,,,,,"Subscriber and covered spouse are both eligible to receive a 50% discount (up to $50 each) on the purchase of an approved wireless activity tracker.  Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200190,18029NY1200190-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Wellness Benefit,,,,,,,,,"Subscriber and covered spouse are both eligible to receive a 50% discount (up to $50 each) on the purchase of an approved wireless activity tracker.  Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200191,18029NY1200191-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Wellness Benefit,,,,,,,,,"Subscriber and covered spouse are both eligible to receive a 50% discount (up to $50 each) on the purchase of an approved wireless activity tracker.  Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1200192,18029NY1200192-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220001,18029NY1220001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220002,18029NY1220002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220009,18029NY1220009-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-02,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220021,18029NY1220021-03,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-02,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220022,18029NY1220022-03,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  This plan does not require referrals to access care.  The deductible is aggregated.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  This plan does not require referrals to access care.  The deductible is aggregated.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-02,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  This plan does not require referrals to access care.  The deductible is aggregated.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220025,18029NY1220025-03,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  This plan does not require referrals to access care.  The deductible is aggregated.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  This plan does not require referrals to access care.  The deductible is aggregated.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-02,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  This plan does not require referrals to access care.  The deductible is aggregated.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1220026,18029NY1220026-03,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240001,18029NY1240001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240003,18029NY1240003-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240004,18029NY1240004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240005,18029NY1240005-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240008,18029NY1240008-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240011,18029NY1240011-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240013,18029NY1240013-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240014,18029NY1240014-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240033,18029NY1240033-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240035,18029NY1240035-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240036,18029NY1240036-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240037,18029NY1240037-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240040,18029NY1240040-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240043,18029NY1240043-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240045,18029NY1240045-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240046,18029NY1240046-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240065,18029NY1240065-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240067,18029NY1240067-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240068,18029NY1240068-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240069,18029NY1240069-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240072,18029NY1240072-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240075,18029NY1240075-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240077,18029NY1240077-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Design,,,,No,,,,,"This plan offers a tiered network of hospitals, facilities and providers developed in partnership with Catholic Health System and Catholic Medical Partners.  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240078,18029NY1240078-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240129,18029NY1240129-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240130,18029NY1240130-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240131,18029NY1240131-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240132,18029NY1240132-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240133,18029NY1240133-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240134,18029NY1240134-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240135,18029NY1240135-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240136,18029NY1240136-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240145,18029NY1240145-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240146,18029NY1240146-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240147,18029NY1240147-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240148,18029NY1240148-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240149,18029NY1240149-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240150,18029NY1240150-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240151,18029NY1240151-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240152,18029NY1240152-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Wellness Benefit,,,,,,,,,"Subscriber and covered spouse are both eligible to receive a 50% discount (up to $50 each) on the purchase of an approved wireless activity tracker.  Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240177,18029NY1240177-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Wellness Benefit,,,,,,,,,"Subscriber and covered spouse are both eligible to receive a 50% discount (up to $50 each) on the purchase of an approved wireless activity tracker.  Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240178,18029NY1240178-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Wellness Benefit,,,,,,,,,"Subscriber and covered spouse are both eligible to receive a 50% discount (up to $50 each) on the purchase of an approved wireless activity tracker.  Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240179,18029NY1240179-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Wellness Benefit,,,,,,,,,"Subscriber and covered spouse are both eligible to receive a 50% discount (up to $50 each) on the purchase of an approved wireless activity tracker.  Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240180,18029NY1240180-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Wellness Benefit,,,,,,,,,"Subscriber and covered spouse are both eligible to receive a 50% discount (up to $50 each) on the purchase of an approved wireless activity tracker.  Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240181,18029NY1240181-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Wellness Benefit,,,,,,,,,"Subscriber and covered spouse are both eligible to receive a 50% discount (up to $50 each) on the purchase of an approved wireless activity tracker.  Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240182,18029NY1240182-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Wellness Benefit,,,,,,,,,"Subscriber and covered spouse are both eligible to receive a 50% discount (up to $50 each) on the purchase of an approved wireless activity tracker.  Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240183,18029NY1240183-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Wellness Benefit,,,,,,,,,"Subscriber and covered spouse are both eligible to receive a 50% discount (up to $50 each) on the purchase of an approved wireless activity tracker.  Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240184,18029NY1240184-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240193,18029NY1240193-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240194,18029NY1240194-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240195,18029NY1240195-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240196,18029NY1240196-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240197,18029NY1240197-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240198,18029NY1240198-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240199,18029NY1240199-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1240200,18029NY1240200-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260001,18029NY1260001-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260002,18029NY1260002-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260009,18029NY1260009-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-02,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-03,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-04,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-05,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260012,18029NY1260012-06,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-02,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-03,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-04,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-05,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1260013,18029NY1260013-06,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1290001,18029NY1290001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300001,18029NY1300001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300003,18029NY1300003-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300004,18029NY1300004-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300005,18029NY1300005-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300008,18029NY1300008-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300011,18029NY1300011-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300013,18029NY1300013-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300014,18029NY1300014-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300097,18029NY1300097-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300099,18029NY1300099-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300100,18029NY1300100-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300101,18029NY1300101-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300104,18029NY1300104-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300107,18029NY1300107-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300109,18029NY1300109-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300110,18029NY1300110-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300113,18029NY1300113-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300114,18029NY1300114-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300115,18029NY1300115-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300116,18029NY1300116-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300117,18029NY1300117-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300118,18029NY1300118-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300119,18029NY1300119-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300120,18029NY1300120-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300121,18029NY1300121-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300122,18029NY1300122-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300123,18029NY1300123-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300124,18029NY1300124-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300125,18029NY1300125-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300126,18029NY1300126-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300127,18029NY1300127-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Nutritional Counseling,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition. Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1300128,18029NY1300128-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310009,18029NY1310009-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310010,18029NY1310010-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310013,18029NY1310013-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-02,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310033,18029NY1310033-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-01,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Telemedicine,,,,,,,,,"When you cannot reach your primary care physician, access a board-certified physician for consultation via online video chat or telephone through our network of participating Telemedicine providers. Applicable copay or deductible will be charged to your credit card. Following your consultation please contact your primary care physician to update your medical records.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,24 Hour Medical Helpline,,,,,,,,,"If you have an urgent health concern and cannot reach your primary care physician, call our Medical Help Line 24 hours a day, 7 days a week to speak with a registered nurse.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-02,Medications Administered in an Office or Outpatient Setting,,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Routine Dental Services (Adult),,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Skilled Nursing Facility,Yes,,,Yes,365,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Generic Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Non-Preferred Brand Drugs,Yes,,,,,,,,"Your drug formulary lists and identifies prescription drugs and the coverage tier that applies. To understand your out-of-pocket prescription drug costs, refer to your member ID card or benefit summary.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Chemotherapy,Yes,,,,,,,,"In addition to the amount you may owe for your office or outpatient visit, a separate member liability applies for medications (infusions, injections and inhalants) administered in an office or outpatient setting.  See benefit ""Medications Administered in an Office or Outpatient Setting"" for specific member liability.",,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Wellness Benefit,,,,,,,,,"Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. You and your covered spouse (or domestic partner as applicable) are required to complete the Well-being Assessment to select your wellness benefit.",Additional EHB Benefit,,,No,No
2019,NY,18029,SERFF,1,3/4/2019 0:00,18029NY1310034,18029NY1310034-03,Design,,,,No,,,,,"This plan offers the full Independent Health network. This plan does not require referrals to access care.  The deductible applies per person (embedded).  The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-01,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-02,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0010001,25303NY0010001-03,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-01,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-02,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-03,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-04,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-05,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0020001,25303NY0020001-06,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-01,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0030001,25303NY0030001-03,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-01,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-02,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0040001,25303NY0040001-03,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-01,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-02,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0050001,25303NY0050001-03,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-01,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-02,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-03,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-05,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0060001,25303NY0060001-06,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-01,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-02,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0070001,25303NY0070001-03,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-01,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-02,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0080001,25303NY0080001-03,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0090001,25303NY0090001-01,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-01,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-02,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0110001,25303NY0110001-03,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-01,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-02,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-03,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-04,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-05,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0140001,25303NY0140001-06,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020005,30798NY0020005-01,Orthodontia - Child,Yes,,,,,,,,"Pre-Authorization Required - Orthodontics to treat serious medical conditions such as: cleft palate, cleft lip and more.",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020005,30798NY0020005-01,Major Dental Care - Child,Yes,,,,,,,,"Pre-Authorization Required - Endodontics, Periodontics, Prosthodontics and Oral Surgery.",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020005,30798NY0020005-01,Basic Dental Care - Adult,,,,,1,Exam(s) per 6 Months,,,Cleanings and Exams,Additional EHB Benefit,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020005,30798NY0020005-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020005,30798NY0020005-01,Major Dental Care - Adult,,,,,,,,,"Pre-Authorization Required - Endodontics*, Periodontics, Prosthodontics and Oral Surgery. *Adult molar root canals have very limited coverage.",Additional EHB Benefit,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020005,30798NY0020005-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020006,30798NY0020006-01,Routine Dental Services (Adult),,,,,,,,,"X-rays, Fillings and Simple Extractions. Full mouth X-rays or panoramic X-rays at 36 month intervals and bitewing X-rays at 6 month intervals.",Additional EHB Benefit,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020006,30798NY0020006-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020006,30798NY0020006-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings)",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020006,30798NY0020006-01,Orthodontia - Child,Yes,,,,,,,,"Pre-Authorization Required - Orthodontics to treat serious medical conditions such as: cleft palate, cleft lip and more.",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020006,30798NY0020006-01,Major Dental Care - Child,Yes,,,,,,,,"Pre-Authorization Required - Endodontics, Periodontics, Prosthodontics and Oral Surgery.",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020006,30798NY0020006-01,Basic Dental Care - Adult,,,,,1,Exam(s) per 6 Months,,,Cleanings and Exams,Additional EHB Benefit,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020006,30798NY0020006-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020006,30798NY0020006-01,Major Dental Care - Adult,,,,,,,,,"Pre-Authorization Required - Endodontics*, Periodontics, Prosthodontics and Oral Surgery. *Adult molar root canals have very limited coverage.",Additional EHB Benefit,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020006,30798NY0020006-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-01,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-02,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0170001,25303NY0170001-03,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-01,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-02,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for the services.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Gym Membership Reimbursement,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,25303,SERFF,1,3/4/2019 0:00,25303NY0200001,25303NY0200001-03,Design,,,,No,,,,,"Fidelis Care members have direct access to a large network of quality providers throughout New York State.   No referrals or paperwork are required to access Fidelis Care providers.  Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots.  Coverage for your childĘs dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals.",Additional EHB Benefit,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010003,30798NY0010003-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010003,30798NY0010003-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010003,30798NY0010003-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings)",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010003,30798NY0010003-01,Orthodontia - Child,Yes,,,,,,,,"Pre-Authorization Required - Orthodontics to treat serious medical conditions such as: cleft palate, cleft lip and more.",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010003,30798NY0010003-01,Major Dental Care - Child,Yes,,,,,,,,"Pre-Authorization Required - Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010003,30798NY0010003-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010003,30798NY0010003-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010003,30798NY0010003-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010003,30798NY0010003-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010004,30798NY0010004-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010004,30798NY0010004-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010004,30798NY0010004-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings)",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010004,30798NY0010004-01,Orthodontia - Child,Yes,,,,,,,,"Pre-Authorization Required - Orthodontics to treat serious medical conditions such as: cleft palate, cleft lip and more.",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010004,30798NY0010004-01,Major Dental Care - Child,Yes,,,,,,,,"Pre-Authorization Required - Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010004,30798NY0010004-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010004,30798NY0010004-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010004,30798NY0010004-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010004,30798NY0010004-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010005,30798NY0010005-01,Routine Dental Services (Adult),,,,,,,,,"X-rays, Fillings and Simple Extractions. Full mouth X-rays or panoramic X-rays at 36 month intervals and bitewing X-rays at 6 month intervals.",Additional EHB Benefit,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010005,30798NY0010005-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010005,30798NY0010005-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings)",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010005,30798NY0010005-01,Orthodontia - Child,Yes,,,,,,,,"Pre-Authorization Required - Orthodontics to treat serious medical conditions such as: cleft palate, cleft lip and more.",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010005,30798NY0010005-01,Major Dental Care - Child,Yes,,,,,,,,"Pre-Authorization Required - Endodontics, Periodontics, Prosthodontics and Oral Surgery.",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010005,30798NY0010005-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,Cleanings and Exams,Additional EHB Benefit,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010005,30798NY0010005-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010005,30798NY0010005-01,Major Dental Care - Adult,,,,,,,,,"Pre-Authorization Required - Endodontics*, Periodontics, Prosthodontics and Oral Surgery. *Adult molar root canals have very limited coverage.",Additional EHB Benefit,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010005,30798NY0010005-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010006,30798NY0010006-01,Routine Dental Services (Adult),,,,,,,,,"X-rays, Fillings and Simple Extractions. Full mouth X-rays or panoramic X-rays at 36 month intervals and bitewing X-rays at 6 month intervals.",Additional EHB Benefit,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010006,30798NY0010006-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010006,30798NY0010006-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings)",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010006,30798NY0010006-01,Orthodontia - Child,Yes,,,,,,,,"Pre-Authorization Required - Orthodontics to treat serious medical conditions such as: cleft palate, cleft lip and more.",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010006,30798NY0010006-01,Major Dental Care - Child,Yes,,,,,,,,"Pre-Authorization Required - Endodontics, Periodontics, Prosthodontics and Oral Surgery.",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010006,30798NY0010006-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,Cleanings and Exams,Additional EHB Benefit,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010006,30798NY0010006-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010006,30798NY0010006-01,Major Dental Care - Adult,,,,,,,,,"Pre-Authorization Required - Endodontics*, Periodontics, Prosthodontics and Oral Surgery. *Adult molar root canals have very limited coverage.",Additional EHB Benefit,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0010006,30798NY0010006-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020003,30798NY0020003-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020003,30798NY0020003-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020003,30798NY0020003-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings)",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020003,30798NY0020003-01,Orthodontia - Child,Yes,,,,,,,,"Pre-Authorization Required - Orthodontics to treat serious medical conditions such as: cleft palate, cleft lip and more.",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020003,30798NY0020003-01,Major Dental Care - Child,Yes,,,,,,,,"Pre-Authorization Required - Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020003,30798NY0020003-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020003,30798NY0020003-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020003,30798NY0020003-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020003,30798NY0020003-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020004,30798NY0020004-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020004,30798NY0020004-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020004,30798NY0020004-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings)",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020004,30798NY0020004-01,Orthodontia - Child,Yes,,,,,,,,"Pre-Authorization Required - Orthodontics to treat serious medical conditions such as: cleft palate, cleft lip and more.",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020004,30798NY0020004-01,Major Dental Care - Child,Yes,,,,,,,,"Pre-Authorization Required - Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020004,30798NY0020004-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020004,30798NY0020004-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020004,30798NY0020004-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020004,30798NY0020004-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020005,30798NY0020005-01,Routine Dental Services (Adult),,,,,,,,,"X-rays, Fillings and Simple Extractions. Full mouth X-rays or panoramic X-rays at 36 month intervals and bitewing X-rays at 6 month intervals.",Additional EHB Benefit,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020005,30798NY0020005-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,30798,SERFF,1,3/4/2019 0:00,30798NY0020005,30798NY0020005-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings)",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480001,36346NY0480001-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480002,36346NY0480002-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480003,36346NY0480003-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-04,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-05,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480014,36346NY0480014-06,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-04,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-05,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480015,36346NY0480015-06,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-04,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-05,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480016,36346NY0480016-06,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480026,36346NY0480026-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480027,36346NY0480027-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480028,36346NY0480028-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480035,36346NY0480035-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480036,36346NY0480036-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440003,44113NY0440003-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440003,44113NY0440003-01,Major Dental Care - Adult,,,,,,,,,"12 Month Waiting Period.  Endodontics, Periodontics, Prosthodontics and Oral Surgery",Not EHB,,,Yes,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440003,44113NY0440003-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440004,44113NY0440004-01,Routine Dental Services (Adult),,,,,,,,,"Exams, cleanings & x-rays",Not EHB,,,Yes,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440004,44113NY0440004-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440004,44113NY0440004-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillngs).  One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440004,44113NY0440004-01,Orthodontia - Child,Yes,,,,,,,,Dentally Necessary Coverage Only.,,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440004,44113NY0440004-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440004,44113NY0440004-01,Basic Dental Care - Adult,,,,,,,,,6 Month Waiting Period.  Fillings and simple extractions.,Not EHB,,,Yes,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440004,44113NY0440004-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440004,44113NY0440004-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440004,44113NY0440004-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440005,44113NY0440005-01,Routine Dental Services (Adult),,,,,,,,,"Exams, cleanings & x-rays",Not EHB,,,Yes,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440005,44113NY0440005-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440005,44113NY0440005-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillngs).  One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440005,44113NY0440005-01,Orthodontia - Child,Yes,,,,,,,,Dentally Necessary Coverage Only.,,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440005,44113NY0440005-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440005,44113NY0440005-01,Basic Dental Care - Adult,,,,,,,,,6 Month Waiting Period.  Fillings and simple extractions.,Not EHB,,,Yes,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440005,44113NY0440005-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440005,44113NY0440005-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440005,44113NY0440005-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440051,44113NY0440051-01,Routine Dental Services (Adult),,,,,,,,,"Exams, cleanings & x-rays",Not EHB,,,Yes,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440051,44113NY0440051-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440051,44113NY0440051-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillngs).  One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440051,44113NY0440051-01,Orthodontia - Child,Yes,,,,,,,,Dentally Necessary Orthodontia: No Waiting Period. Cosmetic Orthodontia Coverage:  12 month waiting period with $1000 Lifetime Maximum,,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440051,44113NY0440051-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440051,44113NY0440051-01,Basic Dental Care - Adult,,,,,,,,,6 Month Waiting Period.  Fillings and simple extractions.,Not EHB,,,Yes,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440051,44113NY0440051-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440051,44113NY0440051-01,Major Dental Care - Adult,,,,,,,,,"12 Month Waiting Period.  Endodontics, Periodontics, Prosthodontics and Oral Surgery",Not EHB,,,Yes,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440051,44113NY0440051-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440051,44113NY0440051-01,Cosmetic Orthodontia,,,,Yes,1000,Dollars per Lifetime,,,12 Month Waiting Period. Child Only.,Not EHB,,,Yes,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440052,44113NY0440052-01,Routine Dental Services (Adult),,,,,,,,,"Exams, cleanings & x-rays",Not EHB,,,Yes,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440052,44113NY0440052-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440052,44113NY0440052-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillngs).  One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440052,44113NY0440052-01,Orthodontia - Child,Yes,,,,,,,,Dentally Necessary Orthodontia: No Waiting Period. Cosmetic Orthodontia Coverage:  12 month waiting period with $1000 Lifetime Maximum,,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440052,44113NY0440052-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440052,44113NY0440052-01,Basic Dental Care - Adult,,,,,,,,,6 Month Waiting Period.  Fillings and simple extractions.,Not EHB,,,Yes,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440052,44113NY0440052-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440052,44113NY0440052-01,Major Dental Care - Adult,,,,,,,,,"12 Month Waiting Period.  Endodontics, Periodontics, Prosthodontics and Oral Surgery",Not EHB,,,Yes,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440052,44113NY0440052-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440052,44113NY0440052-01,Cosmetic Orthodontia,,,,Yes,1000,Dollars per Lifetime,,,12 Month Waiting Period. Child Only.,Not EHB,,,Yes,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0480037,36346NY0480037-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490001,36346NY0490001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490001,36346NY0490001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490001,36346NY0490001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings), One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490001,36346NY0490001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490001,36346NY0490001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490001,36346NY0490001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490001,36346NY0490001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490001,36346NY0490001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490001,36346NY0490001-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490002,36346NY0490002-01,Routine Dental Services (Adult),,,,Yes,750,Dollars per Year,,,"X-rays, Fillings, and Simple Extractions",Not EHB,,,Yes,Yes
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490002,36346NY0490002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490002,36346NY0490002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings), One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490002,36346NY0490002-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490002,36346NY0490002-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490002,36346NY0490002-01,Basic Dental Care - Adult,,,,Yes,2,Visit(s) per Year,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). Annual Benefits Maximum of $750 per year",Not EHB,,,Yes,Yes
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490002,36346NY0490002-01,Orthodontia - Adult,,,,,,,,,Orthodontics,,,,,
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490002,36346NY0490002-01,Major Dental Care - Adult,,,,Yes,750,Dollars per Year,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Not EHB,,,Yes,Yes
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490002,36346NY0490002-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490003,36346NY0490003-01,Routine Dental Services (Adult),,,,Yes,750,Dollars per Year,,,"X-rays, Fillings, and Simple Extractions",Not EHB,,,Yes,Yes
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490003,36346NY0490003-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490003,36346NY0490003-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings), One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490003,36346NY0490003-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490003,36346NY0490003-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490003,36346NY0490003-01,Basic Dental Care - Adult,,,,Yes,2,Visit(s) per Year,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). Annual Benefits Maximum of $750 per year",Not EHB,,,Yes,Yes
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490003,36346NY0490003-01,Orthodontia - Adult,,,,,,,,,Orthodontics,,,,,
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490003,36346NY0490003-01,Major Dental Care - Adult,,,,Yes,750,Dollars per Year,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Not EHB,,,Yes,Yes
2019,NY,36346,SERFF,1,3/4/2019 0:00,36346NY0490003,36346NY0490003-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0280001,42640NY0280001-01,Routine Dental Services (Adult),,,,,,,,,Cleanings and Exams. Patient charge listed is a sample copayment of preventative service D0120 (Periodic oral evaluation - established patient). A complete list of copayments can be obtained from the plans benefit copayment schedule. įActual patient charges will vary based on the procedure. Plan documents are the final arbiter of coverage.,Not EHB,,,Yes,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0280001,42640NY0280001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants). Patient charge listed is a sample copayment of preventative service D0120 (Periodic oral evaluation - established patient). A complete list of copayments can be obtained from the plans benefit copayment schedule. įActual patient charges will vary based on the procedure. Plan documents are the final arbiter of coverage.",,,,No,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0280001,42640NY0280001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0280001,42640NY0280001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics. Patient charge listed is a sample copayment of orthodontic service for D8080 (Comprehensive orthodontic treatment of the adolescent dentition) and is for when orthodontic treatment is deemed medically necessary as defined by your states Pediatric Essential Benefits benchmark definition.  The Pediatric Essential Benefits orthodontic coverage does not include cosmetic treatment.  Plan documents are the final arbiter of coverage.,,,,No,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0280001,42640NY0280001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery. Patient charge listed is a sample copayment of major service D3320 (Endodontic therapy - bicuspid tooth (excluding final restoration). A complete list of copayments can be obtained from the plans benefit copayment schedule.  Actual patient charges will vary based on the procedure but member responsibility for Pediatric Essential Benefits will not exceed the Maximum Out Of Pocket of $350 per child.  Plan documents are the final arbiter of coverage.",,,,No,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0280001,42640NY0280001-01,Basic Dental Care - Adult,,,,,,,,,"X-rays, Fillings and Simple Extractions. Patient charge listed is a sample copayment of basic service D2140 (Amalgam - one surface, primary or permanent). A complete list of copayments can be obtained from the plans benefit copayment schedule. įActual patient charges will vary based on the procedure. Plan documents are the final arbiter of coverage.",Not EHB,,,Yes,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0280001,42640NY0280001-01,Orthodontia - Adult,,,,,,,,,Orthodontics. Patient charge listed is a sample copayment of orthodontic service D8090 (Comprehensive orthodontic treatment of the adult dentition). A complete list of copayments can be obtained from the plans benefit copayment schedule.  Actual patient charges will vary based on the procedure. Plan documents are the final arbiter of coverage.,Not EHB,,,Yes,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0280001,42640NY0280001-01,Major Dental Care - Adult,,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery. Patient charge listed is a sample copayment of major service D3320 (Endodontic therapy - bicuspid tooth (excluding final restoration). A complete list of copayments can be obtained from the plans benefit copayment schedule.  Actual patient charges will vary based on the procedure. Plan documents are the final arbiter of coverage.",Not EHB,,,Yes,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0280001,42640NY0280001-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0300001,42640NY0300001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0300001,42640NY0300001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants). Patient charge listed is a sample copayment of preventative service D0120 (Periodic oral evaluation - established patient). A complete list of copayments can be obtained from the plans benefit copayment schedule.  Actual patient charges will vary based on the procedure but member responsibility for Pediatric Essential Benefits will not exceed the Maximum Out Of Pocket of $350 per child.  Plan documents are the final arbiter of coverage.",,,,No,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0300001,42640NY0300001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0300001,42640NY0300001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics. Patient charge listed is a sample copayment of orthodontic service for D8080 (Comprehensive orthodontic treatment of the adolescent dentition) and is for when orthodontic treatment is deemed medically necessary as defined by your states Pediatric Essential Benefits benchmark definition.  The Pediatric Essential Benefits orthodontic coverage does not include cosmetic treatment.  Plan documents are the final arbiter of coverage.,,,,No,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0300001,42640NY0300001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery. Patient charge listed is a sample copayment of major service D3320 (Endodontic therapy - bicuspid tooth (excluding final restoration). A complete list of copayments can be obtained from the plans benefit copayment schedule.  Actual patient charges will vary based on the procedure but member responsibility for Pediatric Essential Benefits will not exceed the Maximum Out Of Pocket of $350 per child.  Plan documents are the final arbiter of coverage.",,,,No,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0300001,42640NY0300001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0300001,42640NY0300001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0300001,42640NY0300001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0300001,42640NY0300001-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0320001,42640NY0320001-01,Routine Dental Services (Adult),,,,,,,,,Cleanings and Exams. In Network Family Ded for members >19 years is $225 per family; Out of Network Family Ded for members >19 years is $450 per family.  See Schedule of Benefits.,Not EHB,,,Yes,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0320001,42640NY0320001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0320001,42640NY0320001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings)",,,,No,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0320001,42640NY0320001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0320001,42640NY0320001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0320001,42640NY0320001-01,Basic Dental Care - Adult,,,,,,,,,"X-rays, Fillings and Simple Extractions. 6 month waiting period applies.",Not EHB,,,Yes,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0320001,42640NY0320001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0320001,42640NY0320001-01,Major Dental Care - Adult,,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery. 12 month waiting period applies.",Not EHB,,,Yes,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0320001,42640NY0320001-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0330001,42640NY0330001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0330001,42640NY0330001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0330001,42640NY0330001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings)",,,,No,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0330001,42640NY0330001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0330001,42640NY0330001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,Yes
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0330001,42640NY0330001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0330001,42640NY0330001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0330001,42640NY0330001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,42640,SERFF,1,3/4/2019 0:00,42640NY0330001,42640NY0330001-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,42750,SERFF,1,3/4/2019 0:00,42750NY0010001,42750NY0010001-01,Routine Dental Services (Adult),,,,,,,,,"X-Rays, Fillings, and Simple Extractions",,,,,
2019,NY,42750,SERFF,1,3/4/2019 0:00,42750NY0010001,42750NY0010001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (Cleanings, flouride & sealants)",,,,No,Yes
2019,NY,42750,SERFF,1,3/4/2019 0:00,42750NY0010001,42750NY0010001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,Yes
2019,NY,42750,SERFF,1,3/4/2019 0:00,42750NY0010001,42750NY0010001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,Yes
2019,NY,42750,SERFF,1,3/4/2019 0:00,42750NY0010001,42750NY0010001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,Yes
2019,NY,42750,SERFF,1,3/4/2019 0:00,42750NY0010001,42750NY0010001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,42750,SERFF,1,3/4/2019 0:00,42750NY0010001,42750NY0010001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,42750,SERFF,1,3/4/2019 0:00,42750NY0010001,42750NY0010001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,42750,SERFF,1,3/4/2019 0:00,42750NY0010001,42750NY0010001-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,42750,SERFF,1,3/4/2019 0:00,42750NY0010007,42750NY0010007-01,Routine Dental Services (Adult),,,,,,,,,"X-Rays, Fillings, and Simple Extractions. $1,000 plan year benefit maximum.",Not EHB,,,Yes,Yes
2019,NY,42750,SERFF,1,3/4/2019 0:00,42750NY0010007,42750NY0010007-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (Cleanings, flouride & sealants)",,,,No,Yes
2019,NY,42750,SERFF,1,3/4/2019 0:00,42750NY0010007,42750NY0010007-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,Yes
2019,NY,42750,SERFF,1,3/4/2019 0:00,42750NY0010007,42750NY0010007-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,Yes
2019,NY,42750,SERFF,1,3/4/2019 0:00,42750NY0010007,42750NY0010007-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,Yes
2019,NY,42750,SERFF,1,3/4/2019 0:00,42750NY0010007,42750NY0010007-01,Basic Dental Care - Adult,,,,,,,,,"Cleanings and Exams. $1,000 plan year benefit maximum. There is a 6 month waiting period for basic services. TMJ services covered with separate $300 lifetime maximum and 12 month waiting period.",Not EHB,,,Yes,Yes
2019,NY,42750,SERFF,1,3/4/2019 0:00,42750NY0010007,42750NY0010007-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,42750,SERFF,1,3/4/2019 0:00,42750NY0010007,42750NY0010007-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,42750,SERFF,1,3/4/2019 0:00,42750NY0010007,42750NY0010007-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0420001,44113NY0420001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0420001,44113NY0420001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0420001,44113NY0420001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillngs).  One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0420001,44113NY0420001-01,Orthodontia - Child,Yes,,,,,,,,Dentally Necessary Coverage Only.,,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0420001,44113NY0420001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0420001,44113NY0420001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0420001,44113NY0420001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0420001,44113NY0420001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0420001,44113NY0420001-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0420003,44113NY0420003-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0420003,44113NY0420003-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0420003,44113NY0420003-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillngs).  One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0420003,44113NY0420003-01,Orthodontia - Child,Yes,,,,,,,,Dentally Necessary Coverage Only.,,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0420003,44113NY0420003-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0420003,44113NY0420003-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0420003,44113NY0420003-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0420003,44113NY0420003-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0420003,44113NY0420003-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440001,44113NY0440001-01,Routine Dental Services (Adult),,,,,,,,,"Exams, cleanings & x-rays",Not EHB,,,Yes,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440001,44113NY0440001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440001,44113NY0440001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillngs).  One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440001,44113NY0440001-01,Orthodontia - Child,Yes,,,,,,,,Dentally Necessary Coverage Only.,,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440001,44113NY0440001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440001,44113NY0440001-01,Basic Dental Care - Adult,,,,,,,,,6 Month Waiting Period.  Fillings and simple extractions.,Not EHB,,,Yes,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440001,44113NY0440001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440001,44113NY0440001-01,Major Dental Care - Adult,,,,,,,,,"12 Month Waiting Period.  Endodontics, Periodontics, Prosthodontics and Oral Surgery",Not EHB,,,Yes,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440001,44113NY0440001-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440003,44113NY0440003-01,Routine Dental Services (Adult),,,,,,,,,"Exams, cleanings & x-rays",Not EHB,,,Yes,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440003,44113NY0440003-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440003,44113NY0440003-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillngs).  One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440003,44113NY0440003-01,Orthodontia - Child,Yes,,,,,,,,Dentally Necessary Coverage Only.,,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440003,44113NY0440003-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0440003,44113NY0440003-01,Basic Dental Care - Adult,,,,,,,,,6 Month Waiting Period.  Fillings and simple extractions.,Not EHB,,,Yes,Yes
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540126,44113NY0540126-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540127,44113NY0540127-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-04,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540128,44113NY0540128-06,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-04,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-05,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540129,44113NY0540129-06,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540130,44113NY0540130-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540131,44113NY0540131-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540132,44113NY0540132-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540133,44113NY0540133-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,3 PCP office visits with $0 Copayment not subject to Deductible; Subsequent visits Covered in full after Deductible,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,3 PCP office visits with $0 Copayment not subject to Deductible; Subsequent visits Covered in full after Deductible,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540134,44113NY0540134-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,3 PCP office visits with $0 Copayment not subject to Deductible; Subsequent visits Covered in full after Deductible,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,3 PCP office visits with $0 Copayment not subject to Deductible; Subsequent visits Covered in full after Deductible,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540135,44113NY0540135-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540136,44113NY0540136-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540137,44113NY0540137-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-04,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-05,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540138,44113NY0540138-06,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-05,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540139,44113NY0540139-06,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540140,44113NY0540140-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540141,44113NY0540141-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540142,44113NY0540142-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540143,44113NY0540143-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540144,44113NY0540144-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540145,44113NY0540145-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-04,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-05,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540146,44113NY0540146-06,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-04,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540147,44113NY0540147-06,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540148,44113NY0540148-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540149,44113NY0540149-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540150,44113NY0540150-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-01,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-02,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Major Dental Care - Child,Yes,,,,,,,,"Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Substantially Equal,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Dialysis,Yes,,,,,,,,Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Cochlear Implants,,,,,,,,,1 per ear per time covered.,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Gym Membership Reimbursement,,,,,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,44113,SERFF,1,3/4/2019 0:00,44113NY0540151,44113NY0540151-03,Design,,,,No,,,,,Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care.,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450001,49526NY0450001-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450002,49526NY0450002-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450003,49526NY0450003-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-04,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-05,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450014,49526NY0450014-06,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-04,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-05,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450015,49526NY0450015-06,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-04,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-05,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450016,49526NY0450016-06,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-01,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-02,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-03,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-04,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-05,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450017,49526NY0450017-06,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-01,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-02,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-03,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-04,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-05,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450018,49526NY0450018-06,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450026,49526NY0450026-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450027,49526NY0450027-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450028,49526NY0450028-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450029,49526NY0450029-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450030,49526NY0450030-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450035,49526NY0450035-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450036,49526NY0450036-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450037,49526NY0450037-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450038,49526NY0450038-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0450039,49526NY0450039-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460001,49526NY0460001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460001,49526NY0460001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460001,49526NY0460001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings), One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460001,49526NY0460001-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460001,49526NY0460001-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460001,49526NY0460001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460001,49526NY0460001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460001,49526NY0460001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460001,49526NY0460001-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460002,49526NY0460002-01,Routine Dental Services (Adult),,,,Yes,750,Dollars per Year,,,"X-rays, Fillings, and Simple Extractions",Not EHB,,,Yes,Yes
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460002,49526NY0460002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460002,49526NY0460002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings), One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460002,49526NY0460002-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460002,49526NY0460002-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460002,49526NY0460002-01,Basic Dental Care - Adult,,,,Yes,2,Visit(s) per Year,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). Annual Benefits Maximum of $750 per year",Not EHB,,,Yes,Yes
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460002,49526NY0460002-01,Orthodontia - Adult,,,,,,,,,Orthodontics,,,,,
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460002,49526NY0460002-01,Major Dental Care - Adult,,,,Yes,750,Dollars per Year,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Not EHB,,,Yes,Yes
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460002,49526NY0460002-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460003,49526NY0460003-01,Routine Dental Services (Adult),,,,Yes,750,Dollars per Year,,,"X-rays, Fillings, and Simple Extractions",Not EHB,,,Yes,Yes
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460003,49526NY0460003-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Preventive Dental Care (cleanings, fluoride & sealants)",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460003,49526NY0460003-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings), One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460003,49526NY0460003-01,Orthodontia - Child,Yes,,,,,,,,Orthodontics,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460003,49526NY0460003-01,Major Dental Care - Child,Yes,,,,,,,,"Endodontics, Periodontics, Prosthodontics and Oral Surgery",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460003,49526NY0460003-01,Basic Dental Care - Adult,,,,Yes,2,Visit(s) per Year,,,"Routine Dental Care (exams, x-rays, simple extractions & fillings). Annual Benefits Maximum of $750 per year",Not EHB,,,Yes,Yes
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460003,49526NY0460003-01,Orthodontia - Adult,,,,,,,,,Orthodontics,,,,,
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460003,49526NY0460003-01,Major Dental Care - Adult,,,,Yes,750,Dollars per Year,,,"Endodontics Periodontics, Prosthodontics and Oral Surgery",Not EHB,,,Yes,Yes
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0460003,49526NY0460003-01,Accidental Dental,,,,,,,,,,,,,,
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650005,49526NY0650005-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650006,49526NY0650006-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650007,49526NY0650007-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650008,49526NY0650008-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-01,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-02,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-03,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-04,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-05,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650009,49526NY0650009-06,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-01,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-03,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-04,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-05,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650010,49526NY0650010-06,Design,,,,,,,,,"You have a true family deductible, meaning any individual within a family can be held responsible for the entire family amount. Referrals are not required. The deductible does not apply to preventive prescription drugs used to manage asthma, diabetes, high blood pressure, high cholesterol, osteoporosis and stroke; they are outlined on our Preventive Drug List. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650011,49526NY0650011-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650012,49526NY0650012-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650016,49526NY0650016-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-01,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Skilled Nursing Facility,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-02,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Acupuncture,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Nutritional Counseling,,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Wellness Benefit,,,,,,,,,"Each of our plans includes a $250 wellness benefit card to help you stay healthy. This card can be used like a debit card to pay for gym memberships, massage therapy, acupuncture, chiropractic visits, and even at health food stores.   And there is more. If you complete a health assessment, you earn $25 automatically per contract year. Have a family plan? If your covered spouse completes a health assessment, you earn an additional $25. That is $300 to help you and your family stay healthy!",Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,49526,SERFF,1,3/4/2019 0:00,49526NY0650017,49526NY0650017-03,Design,,,,,,,,,"You have an embedded deductible, meaning once any individual has met the individual deductible, subsequent medical costs will be covered for that individual, even if the family deductible has not been satisfied. Referrals are not required. You have access to all participating providers in our network. Your plan is a tiered product with three (3) levels of benefits.  The benefit details are outlined in the Summary of Benefits and Coverage. You have a $250 wellness card, which can be used for gym memberships, massage therapy, acupuncture, chiropractic visits, and at health food stores. Also included are $0 in-network preventive services, such as annual physicals, mammograms, flu shots, and more.",Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-01,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-02,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010001,54235NY0010001-03,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-01,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-02,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010002,54235NY0010002-03,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-01,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010003,54235NY0010003-03,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-01,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-02,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010004,54235NY0010004-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-01,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-02,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-03,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-04,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-05,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010005,54235NY0010005-06,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-01,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-02,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-03,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-04,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-05,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010006,54235NY0010006-06,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-01,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-02,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010013,54235NY0010013-03,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-01,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-02,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010014,54235NY0010014-03,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010015,54235NY0010015-01,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-01,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-02,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010019,54235NY0010019-03,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-01,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-02,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010021,54235NY0010021-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-01,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-02,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-03,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-04,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-05,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010023,54235NY0010023-06,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-01,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Infertility Treatment,Yes,,,No,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every 3 years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a  12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Well Baby Visits and Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-02,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Nutritional Counseling,,,,No,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010025,54235NY0010025-03,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-01,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-02,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-03,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-04,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-05,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010030,54235NY0010030-06,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-01,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-02,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-03,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-04,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-05,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010031,54235NY0010031-06,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-01,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-02,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-03,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-04,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Cochlear Implants,,,,,,,,,One per year per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-05,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010032,54235NY0010032-06,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-01,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-02,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010033,54235NY0010033-03,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-01,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-02,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010034,54235NY0010034-03,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-01,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-02,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Infertility Treatment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Generic Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Non-Preferred Brand Drugs,Yes,,,Yes,30,Days per Month,,,Quantity Level Limits may apply.,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Specialty Drugs,Yes,,,Yes,30,Days per Month,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Durable Medical Equipment,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Well Baby Visits and Care,Yes,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Basic Dental Care - Child,Yes,,,No,,,,,,Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Orthodontia - Child,Yes,,,No,,,,,Coverage is for medically necessary orthodontia only.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.,Not EHB,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Transplant,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Radiation,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Prosthetic Devices,Yes,,,Yes,1,Item(s) per 3 Years,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),Substantially Equal,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Nutritional Counseling,,,,No,,,,,Covered in accordance with USPSTF A or B recommendations,Other Law/Regulation,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Reconstructive Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Breast Reconstructive Surgery,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Family Planning Services,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Sterilization Procedures for Men,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,60 consecutive days per condition per lifetime,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Gym Membership Reimbursement,,,,Yes,200,Dollars per 6 Months,,,$200 per 6 months for subscriber; $100 per 6 months for spouse,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,54235,SERFF,1,3/4/2019 0:00,54235NY0010035,54235NY0010035-03,Design,,,,No,,,,,Referrals requirements to access care (i.e. gatekeeper),Additional EHB Benefit,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Each contract provides up to $125 for Gym Membership, Kids Sports, Massage therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  The Deductible and Out of Pocket Maximum are Embedded.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Each contract provides up to $125 for Gym Membership, Kids Sports, Massage therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  The Deductible and Out of Pocket Maximum are Embedded.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Cochlear Implants,,,,,,,,,One per year per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-02,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Each contract provides up to $125 for Gym Membership, Kids Sports, Massage therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  The Deductible and Out of Pocket Maximum are Embedded.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Cochlear Implants,,,,,,,,,One per year per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140010,56184NY0140010-03,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Each contract provides up to $125 for Gym Membership, Kids Sports, Massage therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  The Deductible and Out of Pocket Maximum are Embedded.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Cochlear Implants,,,,,,,,,One per year per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Each contract provides up to $125 for Gym Membership, Kids Sports, Massage therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  The Deductible and Out of Pocket Maximum are Embedded.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Cochlear Implants,,,,,,,,,One per year per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Cochlear Implants,,,,,,,,,One per year per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140011,56184NY0140011-03,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Each contract provides up to $125 for Gym Membership, Kids Sports, Massage therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  The Deductible and Out of Pocket Maximum are Embedded.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-01,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-02,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-03,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-04,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-05,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140012,56184NY0140012-06,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-02,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-03,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-04,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-05,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140013,56184NY0140013-06,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-01,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-02,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140014,56184NY0140014-03,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-01,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-02,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140015,56184NY0140015-03,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-01,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-02,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140016,56184NY0140016-03,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-01,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-02,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140017,56184NY0140017-03,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-01,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-02,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140030,56184NY0140030-03,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-01,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-02,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Cochlear Implants,,,,,,,,,One per year per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Design,,,,No,,,,,"Your first three (3) visits with your Primary Care Physician (PCP) will take a copay, but those visits will not be subject to the plans Deductible. Subsequent visits to your PCP will be subject to the Deductible and have the same copay applied. Preventive visits you have will be covered in full. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  The Deductible and Out of Pocket Maximum are Embedded.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140031,56184NY0140031-03,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Cochlear Implants,,,,,,,,,One per year per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-01,Design,,,,No,,,,,"Your first three (3) visits with your Primary Care Physician (PCP) will take a copay, but those visits will not be subject to the plans Deductible. Subsequent visits to your PCP will be subject to the Deductible and have the same copay applied. Preventive visits you have will be covered in full. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  The Deductible and Out of Pocket Maximum are Embedded.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Cochlear Implants,,,,,,,,,One per year per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-02,Design,,,,No,,,,,"Your first three (3) visits with your Primary Care Physician (PCP) will take a copay, but those visits will not be subject to the plans Deductible. Subsequent visits to your PCP will be subject to the Deductible and have the same copay applied. Preventive visits you have will be covered in full. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  The Deductible and Out of Pocket Maximum are Embedded.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140034,56184NY0140034-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Cochlear Implants,,,,,,,,,One per year per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-01,Design,,,,No,,,,,"Your first three (3) visits with your Primary Care Physician (PCP) will take a copay, but those visits will not be subject to the plans Deductible. Subsequent visits to your PCP will be subject to the Deductible and have the same copay applied. Preventive visits you have will be covered in full. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  The Deductible and Out of Pocket Maximum are Embedded.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Cochlear Implants,,,,,,,,,One per year per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-02,Design,,,,No,,,,,"Your first three (3) visits with your Primary Care Physician (PCP) will take a copay, but those visits will not be subject to the plans Deductible. Subsequent visits to your PCP will be subject to the Deductible and have the same copay applied. Preventive visits you have will be covered in full. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  The Deductible and Out of Pocket Maximum are Embedded.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Cochlear Implants,,,,,,,,,One per year per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0140035,56184NY0140035-03,Design,,,,No,,,,,"Your first three (3) visits with your Primary Care Physician (PCP) will take a copay, but those visits will not be subject to the plans Deductible. Subsequent visits to your PCP will be subject to the Deductible and have the same copay applied. Preventive visits you have will be covered in full. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  The Deductible and Out of Pocket Maximum are Embedded.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-01,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-02,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150008,56184NY0150008-03,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-01,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-02,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-03,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-04,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-05,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150009,56184NY0150009-06,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-01,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-02,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150010,56184NY0150010-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-01,Design,,,,No,,,,,"Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Acupuncture is covered up to 12 visits per year.  Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share. No referrals are required.  This plan has an Embedded Deductible ( if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-02,Design,,,,No,,,,,"Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Acupuncture is covered up to 12 visits per year.  Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share. No referrals are required.  This plan has an Embedded Deductible ( if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150012,56184NY0150012-03,Design,,,,No,,,,,"Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Acupuncture is covered up to 12 visits per year.  Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share. No referrals are required.  This plan has an Embedded Deductible ( if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-01,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-02,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150015,56184NY0150015-03,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-01,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-02,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-03,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-04,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150017,56184NY0150017-06,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-01,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-02,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150018,56184NY0150018-03,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-01,Design,,,,No,,,,,"Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Acupuncture is covered up to 12 visits per year.  Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share. No referrals are required.  This plan has an Embedded Deductible ( if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-02,Design,,,,No,,,,,"Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Acupuncture is covered up to 12 visits per year.  Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share. No referrals are required.  This plan has an Embedded Deductible ( if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150021,56184NY0150021-03,Design,,,,No,,,,,"Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Acupuncture is covered up to 12 visits per year.  Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share. No referrals are required.  This plan has an Embedded Deductible ( if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-01,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-02,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-03,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-04,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-05,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150092,56184NY0150092-06,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-01,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-02,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-03,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-04,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-05,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0150093,56184NY0150093-06,Design,,,,No,,,,,"This plan features no Out of Pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Acupuncture is covered up to 12 visits per year.  Each contract has up to $125 available for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit and Home Health Care coverage has an extended number of visits.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child. Preferred Facilities take a lesser cost share.  No referrals are required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160017,56184NY0160017-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160018,56184NY0160018-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160019,56184NY0160019-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160020,56184NY0160020-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160021,56184NY0160021-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160022,56184NY0160022-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160023,56184NY0160023-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160024,56184NY0160024-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160049,56184NY0160049-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160050,56184NY0160050-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160051,56184NY0160051-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160052,56184NY0160052-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160053,56184NY0160053-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160054,56184NY0160054-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160055,56184NY0160055-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160056,56184NY0160056-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160089,56184NY0160089-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160090,56184NY0160090-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160091,56184NY0160091-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160092,56184NY0160092-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160093,56184NY0160093-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160094,56184NY0160094-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160095,56184NY0160095-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160096,56184NY0160096-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160097,56184NY0160097-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160098,56184NY0160098-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160099,56184NY0160099-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160100,56184NY0160100-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160101,56184NY0160101-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160102,56184NY0160102-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160103,56184NY0160103-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0160104,56184NY0160104-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Design,,,,No,,,,,"This plan features no out of pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170008,56184NY0170008-01,Design,,,,No,,,,,"This plan features no out of pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170010,56184NY0170010-01,Design,,,,No,,,,,"This plan features no out of pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170012,56184NY0170012-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170014,56184NY0170014-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170022,56184NY0170022-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170024,56184NY0170024-01,Design,,,,No,,,,,"This plan features no out of pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170026,56184NY0170026-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170028,56184NY0170028-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170029,56184NY0170029-01,Design,,,,No,,,,,"This plan features no out of pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170030,56184NY0170030-01,Design,,,,No,,,,,"This plan features no out of pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170035,56184NY0170035-01,Design,,,,No,,,,,"This plan features no out of pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170036,56184NY0170036-01,Design,,,,No,,,,,"This plan features no out of pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170038,56184NY0170038-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170040,56184NY0170040-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170041,56184NY0170041-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170042,56184NY0170042-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170071,56184NY0170071-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170072,56184NY0170072-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170073,56184NY0170073-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170074,56184NY0170074-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170075,56184NY0170075-01,Design,,,,No,,,,,"This plan features no out of pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170076,56184NY0170076-01,Design,,,,No,,,,,"This plan features no out of pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170077,56184NY0170077-01,Design,,,,No,,,,,"This plan features no out of pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170078,56184NY0170078-01,Design,,,,No,,,,,"This plan features no out of pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170079,56184NY0170079-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170080,56184NY0170080-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170081,56184NY0170081-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170082,56184NY0170082-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170083,56184NY0170083-01,Design,,,,No,,,,,"This plan features no out of pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170084,56184NY0170084-01,Design,,,,No,,,,,"This plan features no out of pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170085,56184NY0170085-01,Design,,,,No,,,,,"This plan features no out of pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170086,56184NY0170086-01,Design,,,,No,,,,,"This plan features no out of pocket cost for your first three (3) visits with your Primary Care Physician (PCP) in addition to the preventive visits you have each year that also are covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170087,56184NY0170087-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170088,56184NY0170088-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170089,56184NY0170089-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170090,56184NY0170090-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170091,56184NY0170091-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170092,56184NY0170092-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170093,56184NY0170093-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Cochlear Implants,,,,,,,,,One per year per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Each contract provides up to $125 for Gym Membership, Kids Sports, Massage therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  The Deductible and Out of Pocket Maximum are Embedded.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0170094,56184NY0170094-01,Design,,,,No,,,,,"This plan offers preventive visits covered in full.  Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Cochlear Implants,,,,,,,,,One per year per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Each contract provides up to $125 for Gym Membership, Kids Sports, Massage therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  The Deductible and Out of Pocket Maximum are Embedded.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Cochlear Implants,,,,,,,,,One per year per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190005,56184NY0190005-03,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Each contract provides up to $125 for Gym Membership, Kids Sports, Massage therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  The Deductible and Out of Pocket Maximum are Embedded.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-01,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-02,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-03,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-04,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-05,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190006,56184NY0190006-06,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-01,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-02,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190007,56184NY0190007-03,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-01,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-02,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190008,56184NY0190008-03,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-01,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-02,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Cochlear Implants,,,,,,,,,One per year per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Design,,,,No,,,,,"Your first three (3) visits with your Primary Care Physician (PCP) will take a copay, but those visits will not be subject to the plans Deductible. Subsequent visits to your PCP will be subject to the Deductible and have the same copay applied. Preventive visits you have will be covered in full. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  The Deductible and Out of Pocket Maximum are Embedded.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management,Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190013,56184NY0190013-03,Design,,,,No,,,,,"Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Cochlear Implants,,,,,,,,,One per year per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-01,Design,,,,No,,,,,"Your first three (3) visits with your Primary Care Physician (PCP) will take a copay, but those visits will not be subject to the plans Deductible. Subsequent visits to your PCP will be subject to the Deductible and have the same copay applied. Preventive visits you have will be covered in full. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  The Deductible and Out of Pocket Maximum are Embedded.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Cochlear Implants,,,,,,,,,One per year per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-02,Design,,,,No,,,,,"Your first three (3) visits with your Primary Care Physician (PCP) will take a copay, but those visits will not be subject to the plans Deductible. Subsequent visits to your PCP will be subject to the Deductible and have the same copay applied. Preventive visits you have will be covered in full. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  No referrals required.  The Deductible and Out of Pocket Maximum are Embedded.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0190015,56184NY0190015-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-02,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200004,56184NY0200004-03,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-02,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-03,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-04,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-05,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200005,56184NY0200005-06,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-02,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200006,56184NY0200006-03,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-02,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Embedded Deductible (if applicable) and Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200007,56184NY0200007-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-02,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-03,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Design,,,,No,,,,,"Each Contract provides a National Network of providers.  This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Preventive drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit. Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and an Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-04,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-05,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200008,56184NY0200008-06,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-02,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200009,56184NY0200009-03,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Wellness drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit.  For families, there are Out of Area covered benefits for up to $1000 per Dependent Child.  Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-01,Design,,,,No,,,,,"Each Contract provides a National Network of providers.  This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Preventive drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit. Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and an Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200032,56184NY0200032-03,Design,,,,No,,,,,"Each Contract provides a National Network of providers.  This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Preventive drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit. Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and an Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-01,Design,,,,No,,,,,"Each Contract provides a National Network of providers.  This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Preventive drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit. Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and an Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-02,Design,,,,No,,,,,"Each Contract provides a National Network of providers.  This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Preventive drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit. Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and an Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 visits per year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0200033,56184NY0200033-03,Design,,,,No,,,,,"Each Contract provides a National Network of providers.  This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Preventive drugs are not subject to the plans deductible.  Acupuncture is covered up to 12 visits per year. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs. Telemedicine is a covered benefit. Preferred Facilities take a lesser cost share. No referrals are required. This plan has an Aggregate Deductible and an Embedded Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210005,56184NY0210005-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210006,56184NY0210006-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210011,56184NY0210011-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210012,56184NY0210012-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210014,56184NY0210014-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210015,56184NY0210015-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210017,56184NY0210017-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210018,56184NY0210018-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210031,56184NY0210031-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210032,56184NY0210032-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210033,56184NY0210033-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210034,56184NY0210034-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210035,56184NY0210035-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210036,56184NY0210036-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements ( limit does not apply to internal devices),,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Gym Membership Reimbursement,,,,No,,,,,"Reimbursement arrangement. $125 per Contract for wellness benefits (Gym Membership, Kids Sports, Weight Loss Management, Tobacco Cessation Support or Massage Therapy)",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Design,,,,No,,,,,"This plan features three (3) visits with a  Primary Care Physician (PCP) which are covered in full and are not subject to the Deductible. Each contract provides up to $125 for Gym Membership, Kids Sports, Massage Therapy, Smoking Cessation and Weight Loss Support Programs.Telemedicine is a covered benefit. No referrals required.  The Deductible and Out of Pocket Maximum are Embedded.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210037,56184NY0210037-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Routine Eye Exam (Adult),,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Home Health Care Services,Yes,,,Yes,60,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Skilled Nursing Facility,Yes,,,,,,,,,Other Law/Regulation,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Outpatient Rehabilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Habilitation Services,Yes,,,Yes,54,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Acupuncture,,,,Yes,12,Visit(s) per Year,,,12 Visits per Year,Substantially Equal,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Rehabilitative Speech Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,54,Visit(s) per Year,,,54 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,Substituted,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Prosthetic Devices,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Breast Reconstructive Surgery,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Cardiac Rehabilitation,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Second Opinion,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Assistive Communication Devices,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Autologous Blood Banking,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Diabetic Equipment and Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Family Planning Services,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Medical Supplies,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Preadmission Testing,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Prostate Cancer Screening,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Sterilization Procedures for Men,,,,,,,,,,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Gym Membership Reimbursement,,,,No,,,,,"Up to $125 reimbursement for Gym and Fitness Club Membership, Youth Sports, Healthy Weight Support Programs, Tobacco Cessation or Massage Therapy and up to $200 earnable for completing activities through MVPs Website.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Telemedicine,,,,,,,,,Online internet consultations with a MVP approved telemedicine vendor,Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0210038,56184NY0210038-01,Design,,,,No,,,,,"This plan is a qualified High Deductible Health Plan (HDHP) that can be paired with a tax advantaged Health Savings Account (HSA). Pediatric Dental Care is included with the plan. Acupuncture is covered up to 12 visits and Home Health Care coverage has an extended number of visits. Adult Vision Care and Eyewear benefits are covered. You have up to $325 per contract per plan year that can be redeemed for Gym Membership, Kids Sports, Massage Therapy, Weight Loss or Tobacco Cessation support programs and other wellness activities.  No referrals are required. The Schedule of Benefits can be used to determine if the plan has an Embedded or Aggregate Deductible or Out of Pocket Maximum.",Not EHB,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,56184,SERFF,1,3/4/2019 0:00,56184NY0220002,56184NY0220002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030001,61405NY0030001-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030002,61405NY0030002-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030003,61405NY0030003-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030004,61405NY0030004-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030005,61405NY0030005-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030006,61405NY0030006-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030007,61405NY0030007-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030008,61405NY0030008-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030009,61405NY0030009-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030010,61405NY0030010-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030011,61405NY0030011-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030012,61405NY0030012-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030013,61405NY0030013-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030014,61405NY0030014-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030015,61405NY0030015-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030016,61405NY0030016-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030017,61405NY0030017-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030018,61405NY0030018-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030019,61405NY0030019-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030020,61405NY0030020-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030021,61405NY0030021-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030022,61405NY0030022-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030023,61405NY0030023-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030024,61405NY0030024-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030025,61405NY0030025-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030026,61405NY0030026-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030027,61405NY0030027-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030028,61405NY0030028-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030029,61405NY0030029-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030030,61405NY0030030-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030031,61405NY0030031-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030032,61405NY0030032-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030033,61405NY0030033-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030034,61405NY0030034-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030035,61405NY0030035-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030036,61405NY0030036-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030037,61405NY0030037-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030038,61405NY0030038-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030039,61405NY0030039-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030040,61405NY0030040-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030041,61405NY0030041-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030042,61405NY0030042-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030043,61405NY0030043-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030044,61405NY0030044-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030045,61405NY0030045-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030046,61405NY0030046-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030047,61405NY0030047-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030048,61405NY0030048-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030049,61405NY0030049-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030050,61405NY0030050-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030051,61405NY0030051-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030052,61405NY0030052-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030053,61405NY0030053-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030054,61405NY0030054-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030055,61405NY0030055-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030056,61405NY0030056-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030057,61405NY0030057-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030058,61405NY0030058-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030059,61405NY0030059-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030060,61405NY0030060-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030061,61405NY0030061-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030062,61405NY0030062-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030063,61405NY0030063-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030064,61405NY0030064-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030065,61405NY0030065-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030066,61405NY0030066-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030067,61405NY0030067-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030068,61405NY0030068-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030069,61405NY0030069-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030070,61405NY0030070-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030071,61405NY0030071-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030072,61405NY0030072-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030073,61405NY0030073-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030074,61405NY0030074-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030075,61405NY0030075-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030076,61405NY0030076-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030077,61405NY0030077-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030078,61405NY0030078-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030079,61405NY0030079-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030080,61405NY0030080-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030081,61405NY0030081-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030082,61405NY0030082-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030083,61405NY0030083-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030084,61405NY0030084-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030085,61405NY0030085-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030086,61405NY0030086-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030087,61405NY0030087-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Routine Dental Services (Adult),,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Routine Eye Exam (Adult),,,,,1,Exam(s) per Year,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Basic Dental Care - Adult,,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Orthodontia - Adult,,,,,,,,,Only if medically necessary,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Major Dental Care - Adult,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Family Planning Services,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Sterilization Procedures for Men,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Telemedicine,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Design,,,,Yes,1,Item(s) per Year,,,"Healthfirst Pro Plus EPO plans are health insurance plans that offer complete coverage with extra benefits, including:  Adult dental care and vision care (including contacts, lenses, and frames), telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Eye Glasses for Adults,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030088,61405NY0030088-01,Contact Lenses,,,,,,,,,"An allowance applies to covered lenses and frames, and contact lenses",Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030089,61405NY0030089-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030090,61405NY0030090-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030091,61405NY0030091-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030092,61405NY0030092-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030093,61405NY0030093-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030094,61405NY0030094-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030095,61405NY0030095-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030096,61405NY0030096-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030097,61405NY0030097-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030098,61405NY0030098-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030099,61405NY0030099-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030100,61405NY0030100-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030101,61405NY0030101-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030102,61405NY0030102-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030103,61405NY0030103-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030104,61405NY0030104-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030105,61405NY0030105-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030106,61405NY0030106-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030107,61405NY0030107-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030108,61405NY0030108-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030109,61405NY0030109-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030110,61405NY0030110-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030111,61405NY0030111-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Routine Dental Services (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Private-Duty Nursing,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Routine Eye Exam (Adult),,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Cosmetic Surgery,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Routine Foot Care,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Acupuncture,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Weight Loss Programs,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Basic Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Orthodontia - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Major Dental Care - Adult,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Transplant,Yes,,,,,,,,"Transplants determined to be non-experimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.",,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Nutritional Counseling,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Cochlear Implants,,,,,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,"An allowance applies to covered lenses and frames, and contact lenses",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Gym Membership Reimbursement,,,,,,,,,Up to $400 during coverage year; up to an additional $200 during coverage year for Spouse,Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Telemedicine,,,,,,,,,,Not EHB,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Design,,,,,,,,,"Healthfirst Pro EPO plans are health insurance plans that offer complete coverage with extra benefits, including: telemedicine, acupuncture, a gym/exercise reward program (up to $400 back per year), 10 Essential Health Benefits, like emergency services, hospital stays, maternity care, prescription drugs, and more ū free preventive/annual checkups, Bronze plans are HSA Compatible All Healthfirst Total EPO Plans include access to a large network of thousands of providers.  No referrals required.",Additional EHB Benefit,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Eye Glasses for Adults,,,,,,,,,,,,,No,No
2019,NY,61405,SERFF,1,3/4/2019 0:00,61405NY0030112,61405NY0030112-01,Contact Lenses,,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010001,74289NY0010001-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0010002,74289NY0010002-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030001,74289NY0030001-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0030002,74289NY0030002-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-04,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-05,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050001,74289NY0050001-06,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-04,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-05,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0050002,74289NY0050002-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080001,74289NY0080001-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0080002,74289NY0080002-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0110001,74289NY0110001-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0120001,74289NY0120001-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0130001,74289NY0130001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-05,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0140001,74289NY0140001-06,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0160001,74289NY0160001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520001,74289NY0520001-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0520002,74289NY0520002-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-04,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-05,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640001,74289NY0640001-06,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-04,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0640002,74289NY0640002-06,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650001,74289NY0650001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0650002,74289NY0650002-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780001,74289NY0780001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0780002,74289NY0780002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790001,74289NY0790001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0790002,74289NY0790002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800001,74289NY0800001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0800002,74289NY0800002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810001,74289NY0810001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0810002,74289NY0810002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820001,74289NY0820001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0820002,74289NY0820002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830001,74289NY0830001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0830002,74289NY0830002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840001,74289NY0840001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0840002,74289NY0840002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850001,74289NY0850001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0850002,74289NY0850002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860001,74289NY0860001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0860002,74289NY0860002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870001,74289NY0870001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0870002,74289NY0870002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880001,74289NY0880001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0880002,74289NY0880002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890001,74289NY0890001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0890002,74289NY0890002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900001,74289NY0900001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0900002,74289NY0900002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910001,74289NY0910001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0910002,74289NY0910002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920001,74289NY0920001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0920002,74289NY0920002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930001,74289NY0930001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0930002,74289NY0930002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980001,74289NY0980001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0980002,74289NY0980002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990001,74289NY0990001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY0990002,74289NY0990002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000001,74289NY1000001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1000002,74289NY1000002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010001,74289NY1010001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1010002,74289NY1010002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020001,74289NY1020001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1020002,74289NY1020002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030001,74289NY1030001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1030002,74289NY1030002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040001,74289NY1040001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1040002,74289NY1040002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050001,74289NY1050001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1050002,74289NY1050002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100001,74289NY1100001-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1100002,74289NY1100002-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-04,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-05,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110001,74289NY1110001-06,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-04,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-05,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1110002,74289NY1110002-06,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120001,74289NY1120001-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-02,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Prosthetic Devices,Yes,,,,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Applied Behavior Analysis Based Therapies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Breast Reconstructive Surgery,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Cardiac Rehabilitation,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Cochlear Implants,,,,,,,,,One per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Second Opinion,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Assistive Communication Devices,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Autologous Blood Banking,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Diabetic Equipment and Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Medical Supplies,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Preadmission Testing,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Prostate Cancer Screening,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Step Tracking,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1120002,74289NY1120002-03,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Coverage for acupuncture; Step tracking rewards for staying active; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160001,74289NY1160001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1160002,74289NY1160002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170001,74289NY1170001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1170002,74289NY1170002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180001,74289NY1180001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1180002,74289NY1180002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190001,74289NY1190001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1190002,74289NY1190002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240001,74289NY1240001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1240002,74289NY1240002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250001,74289NY1250001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1250002,74289NY1250002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260001,74289NY1260001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1260002,74289NY1260002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270001,74289NY1270001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1270002,74289NY1270002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280001,74289NY1280001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1280002,74289NY1280002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290001,74289NY1290001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1290002,74289NY1290002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300001,74289NY1300001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1300002,74289NY1300002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310001,74289NY1310001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1310002,74289NY1310002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320001,74289NY1320001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1320002,74289NY1320002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330001,74289NY1330001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1330002,74289NY1330002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340001,74289NY1340001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1340002,74289NY1340002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350001,74289NY1350001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1350002,74289NY1350002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400001,74289NY1400001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1400002,74289NY1400002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410001,74289NY1410001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1410002,74289NY1410002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420001,74289NY1420001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1420002,74289NY1420002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430001,74289NY1430001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1430002,74289NY1430002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440001,74289NY1440001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1440002,74289NY1440002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450001,74289NY1450001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1450002,74289NY1450002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460001,74289NY1460001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1460002,74289NY1460002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470001,74289NY1470001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1470002,74289NY1470002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520001,74289NY1520001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1520002,74289NY1520002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530001,74289NY1530001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1530002,74289NY1530002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540001,74289NY1540001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1540002,74289NY1540002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550001,74289NY1550001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1550002,74289NY1550002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560001,74289NY1560001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1560002,74289NY1560002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570001,74289NY1570001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1570002,74289NY1570002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580001,74289NY1580001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1580002,74289NY1580002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590001,74289NY1590001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1590002,74289NY1590002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640001,74289NY1640001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1640002,74289NY1640002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650001,74289NY1650001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1650002,74289NY1650002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660001,74289NY1660001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1660002,74289NY1660002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670001,74289NY1670001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1670002,74289NY1670002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680001,74289NY1680001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1680002,74289NY1680002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690001,74289NY1690001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1690002,74289NY1690002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700001,74289NY1700001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1700002,74289NY1700002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710001,74289NY1710001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1710002,74289NY1710002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720001,74289NY1720001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1720002,74289NY1720002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730001,74289NY1730001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1730002,74289NY1730002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740001,74289NY1740001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1740002,74289NY1740002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750001,74289NY1750001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1750002,74289NY1750002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760001,74289NY1760001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1760002,74289NY1760002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770001,74289NY1770001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1770002,74289NY1770002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780001,74289NY1780001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1780002,74289NY1780002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790001,74289NY1790001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1790002,74289NY1790002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840001,74289NY1840001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1840002,74289NY1840002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850001,74289NY1850001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1850002,74289NY1850002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860001,74289NY1860001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1860002,74289NY1860002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870001,74289NY1870001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1870002,74289NY1870002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880001,74289NY1880001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1880002,74289NY1880002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890001,74289NY1890001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1890002,74289NY1890002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900001,74289NY1900001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1900002,74289NY1900002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910001,74289NY1910001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1910002,74289NY1910002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960001,74289NY1960001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1960002,74289NY1960002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970001,74289NY1970001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1970002,74289NY1970002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980001,74289NY1980001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1980002,74289NY1980002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990001,74289NY1990001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY1990002,74289NY1990002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040001,74289NY2040001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2040002,74289NY2040002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050001,74289NY2050001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2050002,74289NY2050002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060001,74289NY2060001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2060002,74289NY2060002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070001,74289NY2070001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2070002,74289NY2070002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080001,74289NY2080001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2080002,74289NY2080002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090001,74289NY2090001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2090002,74289NY2090002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100001,74289NY2100001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2100002,74289NY2100002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110001,74289NY2110001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2110002,74289NY2110002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120001,74289NY2120001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2120002,74289NY2120002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130001,74289NY2130001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2130002,74289NY2130002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140001,74289NY2140001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2140002,74289NY2140002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150001,74289NY2150001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2150002,74289NY2150002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200001,74289NY2200001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2200002,74289NY2200002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210001,74289NY2210001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2210002,74289NY2210002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220001,74289NY2220001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2220002,74289NY2220002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230001,74289NY2230001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2230002,74289NY2230002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240001,74289NY2240001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2240002,74289NY2240002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250001,74289NY2250001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2250002,74289NY2250002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260001,74289NY2260001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2260002,74289NY2260002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270001,74289NY2270001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2270002,74289NY2270002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320001,74289NY2320001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2320002,74289NY2320002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330001,74289NY2330001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2330002,74289NY2330002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340001,74289NY2340001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2340002,74289NY2340002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350001,74289NY2350001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2350002,74289NY2350002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360001,74289NY2360001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2360002,74289NY2360002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370001,74289NY2370001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2370002,74289NY2370002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380001,74289NY2380001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2380002,74289NY2380002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390001,74289NY2390001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2390002,74289NY2390002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400001,74289NY2400001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2400002,74289NY2400002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410001,74289NY2410001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2410002,74289NY2410002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420001,74289NY2420001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2420002,74289NY2420002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430001,74289NY2430001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2430002,74289NY2430002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440001,74289NY2440001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2440002,74289NY2440002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450001,74289NY2450001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2450002,74289NY2450002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460001,74289NY2460001-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Family Planning Services,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Sterilization Procedures for Men,,,,,,,,,,Additional EHB Benefit,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2460002,74289NY2460002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470001,74289NY2470001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Specialist Visit,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Infertility Treatment,Yes,,,,,,,,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Urgent Care Centers or Facilities,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Emergency Room Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Emergency Transportation/Ambulance,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Inpatient Physician and Surgical Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Bariatric Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Prenatal and Postnatal Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Mental/Behavioral Health Outpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Mental/Behavioral Health Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Substance Abuse Disorder Outpatient Services,Yes,,,,,,,,Also includes 20 visits per year for family counseling.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Substance Abuse Disorder Inpatient Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Generic Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Non-Preferred Brand Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Specialty Drugs,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Chiropractic Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Durable Medical Equipment,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Hearing Aids,Yes,,,Yes,1,Item(s) per 3 Years,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Preventive Care/Screening/Immunization,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Year,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Year,,,One prescribed lenses & frames in a 12-month period.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Dental Check-Up for Children,Yes,,,Yes,1,Exam(s) per 6 Months,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Well Baby Visits and Care,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Laboratory Outpatient and Professional Services,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,X-rays and Diagnostic Imaging,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Basic Dental Care - Child,Yes,,,Yes,1,Exam(s) per 6 Months,,,One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Orthodontia - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Major Dental Care - Child,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Not EHB,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Transplant,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Accidental Dental,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Dialysis,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Allergy Testing,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Chemotherapy,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Radiation,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Diabetes Education,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Prosthetic Devices,Yes,,,,,,,,We cover the cost of repair or replacement when made necessary by normal wear and tear.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Infusion Therapy,Yes,,,,,,,,Any visits for home infusion therapy count towards Your home health care visit limit.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,,,,,,Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Reconstructive Surgery,Yes,,,,,,,,,,,,No,No
2019,NY,74289,SERFF,1,3/4/2019 0:00,74289NY2470002,74289NY2470002-01,Design,,,,,,,,,"Plan highlights include: Free 24/7 calls with doctors; Free preventive care such as a checkup, flu shots, and some birth control; Free prenatal care for expecting mothers; Savings for medical care in our network; Emergency care covered anywhere in the world; No referrals required; Single-tier EPO network; and Embedded deductibles.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880002,78124NY0880002-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880004,78124NY0880004-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880006,78124NY0880006-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880008,78124NY0880008-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0880010,78124NY0880010-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890002,78124NY0890002-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890004,78124NY0890004-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890006,78124NY0890006-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-04,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-05,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890008,78124NY0890008-06,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-04,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-05,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890010,78124NY0890010-06,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-04,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-05,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890012,78124NY0890012-06,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890014,78124NY0890014-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible and preventive care is free.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible and preventive care is free.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890016,78124NY0890016-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible and preventive care is free.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible and preventive care is free.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible and preventive care is free.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890018,78124NY0890018-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible and preventive care is free.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible and preventive care is free.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890020,78124NY0890020-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible and preventive care is free.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible and preventive care is free.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible and preventive care is free.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-04,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible and preventive care is free.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-05,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible and preventive care is free.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890024,78124NY0890024-06,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible and preventive care is free.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible and preventive care is free.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible and preventive care is free.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible and preventive care is free.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-04,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible and preventive care is free.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-05,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible and preventive care is free.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0890026,78124NY0890026-06,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900002,78124NY0900002-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900004,78124NY0900004-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum..",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900006,78124NY0900006-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-04,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-05,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900008,78124NY0900008-06,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-04,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-05,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900010,78124NY0900010-06,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900012,78124NY0900012-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900014,78124NY0900014-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900016,78124NY0900016-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900018,78124NY0900018-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0900020,78124NY0900020-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Design,,,,,,,,,"No referrals required to see a specialist and you do not need to identify a Primary Care Physician. Free preventive care. This is a tiered network plan that offers you lower out of pocket costs when you see a provider or use a facility in our (tier 1) preferred network.  You will still have access to the Excellus BlueCross BlueShield (tier 2) or non preferred network, but will pay more when you use this network.  This plan has an embedded deductible, so each family member is only responsible for his or her own deductible. There is a separate deductible for both preferred network and non-preferred network services. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers and discounts on fitness gear, weight-loss programs and more.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician.  Free preventive care.  Coverage for services in network only with access to 100% of local hospitals and 98% of doctors through-out 31 counties in New York State. If you are traveling, BlueCard« provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0910002,78124NY0910002-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Design,,,,,,,,,"No referrals required to see a specialist and you do not need to identify a Primary Care Physician. Free preventive care. This is a tiered network plan that offers you lower out of pocket costs when you see a provider or use a facility in our (tier 1) preferred network.  You will still have access to the Excellus BlueCross BlueShield (tier 2) or non preferred network, but will pay more when you use this network.  This plan has an embedded deductible, so each family member is only responsible for his or her own deductible. There is a separate deductible for both preferred network and non-preferred network services. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers and discounts on fitness gear, weight-loss programs and more.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Design,,,,,,,,,"No referrals required to see a specialist and you do not need to identify a Primary Care Physician. Free preventive care. This is a tiered network plan that offers you lower out of pocket costs when you see a provider or use a facility in our (tier 1) preferred network.  You will still have access to the Excellus BlueCross BlueShield (tier 2) or non preferred network, but will pay more when you use this network.  This plan has an embedded deductible, so each family member is only responsible for his or her own deductible. There is a separate deductible for both preferred network and non-preferred network services. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers and discounts on fitness gear, weight-loss programs and more.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Design,,,,,,,,,"No referrals required to see a specialist and you do not need to identify a Primary Care Physician. Free preventive care. This is a tiered network plan that offers you lower out of pocket costs when you see a provider or use a facility in our (tier 1) preferred network.  You will still have access to the Excellus BlueCross BlueShield (tier 2) or non preferred network, but will pay more when you use this network.  This plan has an embedded deductible, so each family member is only responsible for his or her own deductible. There is a separate deductible for both preferred network and non-preferred network services. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers and discounts on fitness gear, weight-loss programs and more.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920002,78124NY0920002-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Design,,,,,,,,,"No referrals required to see a specialist and you do not need to identify a Primary Care Physician. Free preventive care. This is a tiered network plan that offers you lower out of pocket costs when you see a provider or use a facility in our (tier 1) preferred network.  You will still have access to the Excellus BlueCross BlueShield (tier 2) or non preferred network, but will pay more when you use this network.  This plan has an embedded deductible, so each family member is only responsible for his or her own deductible. There is a separate deductible for both preferred network and non-preferred network services. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers and discounts on fitness gear, weight-loss programs and more.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Design,,,,,,,,,"No referrals required to see a specialist and you do not need to identify a Primary Care Physician. Free preventive care. This is a tiered network plan that offers you lower out of pocket costs when you see a provider or use a facility in our (tier 1) preferred network.  You will still have access to the Excellus BlueCross BlueShield (tier 2) or non preferred network, but will pay more when you use this network.  This plan has an embedded deductible, so each family member is only responsible for his or her own deductible. There is a separate deductible for both preferred network and non-preferred network services. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers and discounts on fitness gear, weight-loss programs and more.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920004,78124NY0920004-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Design,,,,,,,,,"No referrals required to see a specialist and you do not need to identify a Primary Care Physician. Free preventive care. This is a tiered network plan that offers you lower out of pocket costs when you see a provider or use a facility in our (tier 1) preferred network.  You will still have access to the Excellus BlueCross BlueShield (tier 2) or non preferred network, but will pay more when you use this network.  This plan has an embedded deductible, so each family member is only responsible for his or her own deductible. There is a separate deductible for both preferred network and non-preferred network services. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers and discounts on fitness gear, weight-loss programs and more.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Design,,,,,,,,,"No referrals required to see a specialist and you do not need to identify a Primary Care Physician. Free preventive care. This is a tiered network plan that offers you lower out of pocket costs when you see a provider or use a facility in our (tier 1) preferred network.  You will still have access to the Excellus BlueCross BlueShield (tier 2) or non preferred network, but will pay more when you use this network.  This plan has an embedded deductible, so each family member is only responsible for his or her own deductible. There is a separate deductible for both preferred network and non-preferred network services. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers and discounts on fitness gear, weight-loss programs and more.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Design,,,,,,,,,"No referrals required to see a specialist and you do not need to identify a Primary Care Physician. Free preventive care. This is a tiered network plan that offers you lower out of pocket costs when you see a provider or use a facility in our (tier 1) preferred network.  You will still have access to the Excellus BlueCross BlueShield (tier 2) or non preferred network, but will pay more when you use this network.  This plan has an embedded deductible, so each family member is only responsible for his or her own deductible. There is a separate deductible for both preferred network and non-preferred network services. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers and discounts on fitness gear, weight-loss programs and more.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Design,,,,,,,,,"No referrals required to see a specialist and you do not need to identify a Primary Care Physician. Free preventive care. This is a tiered network plan that offers you lower out of pocket costs when you see a provider or use a facility in our (tier 1) preferred network.  You will still have access to the Excellus BlueCross BlueShield (tier 2) or non preferred network, but will pay more when you use this network.  This plan has an embedded deductible, so each family member is only responsible for his or her own deductible. There is a separate deductible for both preferred network and non-preferred network services. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers and discounts on fitness gear, weight-loss programs and more.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-04,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Design,,,,,,,,,"No referrals required to see a specialist and you do not need to identify a Primary Care Physician. Free preventive care. This is a tiered network plan that offers you lower out of pocket costs when you see a provider or use a facility in our (tier 1) preferred network.  You will still have access to the Excellus BlueCross BlueShield (tier 2) or non preferred network, but will pay more when you use this network.  This plan has an embedded deductible, so each family member is only responsible for his or her own deductible. There is a separate deductible for both preferred network and non-preferred network services. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers and discounts on fitness gear, weight-loss programs and more.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-05,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Design,,,,,,,,,"No referrals required to see a specialist and you do not need to identify a Primary Care Physician. Free preventive care. This is a tiered network plan that offers you lower out of pocket costs when you see a provider or use a facility in our (tier 1) preferred network.  You will still have access to the Excellus BlueCross BlueShield (tier 2) or non preferred network, but will pay more when you use this network.  This plan has an embedded deductible, so each family member is only responsible for his or her own deductible. There is a separate deductible for both preferred network and non-preferred network services. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers and discounts on fitness gear, weight-loss programs and more.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920006,78124NY0920006-06,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Design,,,,,,,,,"No referrals required to see a specialist and you do not need to identify a Primary Care Physician. Free preventive care. This is a tiered network plan that offers you lower out of pocket costs when you see a provider or use a facility in our (tier 1) preferred network.  You will still have access to the Excellus BlueCross BlueShield (tier 2) or non preferred network, but will pay more when you use this network.  This plan has an embedded deductible, so each family member is only responsible for his or her own deductible. There is a separate deductible for both preferred network and non-preferred network services. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers and discounts on fitness gear, weight-loss programs and more.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Design,,,,,,,,,"No referrals required to see a specialist and you do not need to identify a Primary Care Physician. Free preventive care. This is a tiered network plan that offers you lower out of pocket costs when you see a provider or use a facility in our (tier 1) preferred network.  You will still have access to the Excellus BlueCross BlueShield (tier 2) or non preferred network, but will pay more when you use this network.  This plan has an embedded deductible, so each family member is only responsible for his or her own deductible. There is a separate deductible for both preferred network and non-preferred network services. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers and discounts on fitness gear, weight-loss programs and more.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Design,,,,,,,,,"No referrals required to see a specialist and you do not need to identify a Primary Care Physician. Free preventive care. This is a tiered network plan that offers you lower out of pocket costs when you see a provider or use a facility in our (tier 1) preferred network.  You will still have access to the Excellus BlueCross BlueShield (tier 2) or non preferred network, but will pay more when you use this network.  This plan has an embedded deductible, so each family member is only responsible for his or her own deductible. There is a separate deductible for both preferred network and non-preferred network services. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers and discounts on fitness gear, weight-loss programs and more.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Design,,,,,,,,,"No referrals required to see a specialist and you do not need to identify a Primary Care Physician. Free preventive care. This is a tiered network plan that offers you lower out of pocket costs when you see a provider or use a facility in our (tier 1) preferred network.  You will still have access to the Excellus BlueCross BlueShield (tier 2) or non preferred network, but will pay more when you use this network.  This plan has an embedded deductible, so each family member is only responsible for his or her own deductible. There is a separate deductible for both preferred network and non-preferred network services. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers and discounts on fitness gear, weight-loss programs and more.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-04,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Design,,,,,,,,,"No referrals required to see a specialist and you do not need to identify a Primary Care Physician. Free preventive care. This is a tiered network plan that offers you lower out of pocket costs when you see a provider or use a facility in our (tier 1) preferred network.  You will still have access to the Excellus BlueCross BlueShield (tier 2) or non preferred network, but will pay more when you use this network.  This plan has an embedded deductible, so each family member is only responsible for his or her own deductible. There is a separate deductible for both preferred network and non-preferred network services. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers and discounts on fitness gear, weight-loss programs and more.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-05,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Design,,,,,,,,,"No referrals required to see a specialist and you do not need to identify a Primary Care Physician. Free preventive care. This is a tiered network plan that offers you lower out of pocket costs when you see a provider or use a facility in our (tier 1) preferred network.  You will still have access to the Excellus BlueCross BlueShield (tier 2) or non preferred network, but will pay more when you use this network.  This plan has an embedded deductible, so each family member is only responsible for his or her own deductible. There is a separate deductible for both preferred network and non-preferred network services. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program. Access to our free Healthy Perks program including a 24/7 Nurse Call Line and Blue365 offers and discounts on fitness gear, weight-loss programs and more.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0920008,78124NY0920008-06,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930002,78124NY0930002-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930004,78124NY0930004-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930006,78124NY0930006-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930008,78124NY0930008-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0930010,78124NY0930010-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940002,78124NY0940002-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940004,78124NY0940004-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940006,78124NY0940006-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-04,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-05,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940008,78124NY0940008-06,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-04,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-05,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940010,78124NY0940010-06,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-04,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-05,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940012,78124NY0940012-06,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940014,78124NY0940014-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940016,78124NY0940016-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible.  Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible.  Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible.  Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible.  Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940018,78124NY0940018-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible.  Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible.  Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible.  Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940020,78124NY0940020-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible.  Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible.  Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible.  Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible.  Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-04,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible.  Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-05,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible.  Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940024,78124NY0940024-06,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible.  Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible.  Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible.  Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-04,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible.  Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-05,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Members pay a low copay for their first 3 Primary Care Visits as they are not subject to the plan deductible.  Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0940026,78124NY0940026-06,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950002,78124NY0950002-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950004,78124NY0950004-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950006,78124NY0950006-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-04,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-05,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950008,78124NY0950008-06,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-04,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-05,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950010,78124NY0950010-06,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950012,78124NY0950012-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950014,78124NY0950014-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950016,78124NY0950016-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950018,78124NY0950018-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-02,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0950020,78124NY0950020-03,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Eating Disorder Treatment,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Design,,,,,,,,,"No referrals required and you do not need to identify a Primary Care Physician. Coverage for services in network only with access to our large local network through-out 39 counties in New York State. Preventive care is free, Telemedicine is available and  each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam.  Get paid up to $600 with ExerciseRewards; a gym and fitness class reward program. Access to our free Tools for Healthy Living including a 24/7 Nurse Call Line.  This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0960002,78124NY0960002-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980001,78124NY0980001-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980002,78124NY0980002-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980003,78124NY0980003-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980004,78124NY0980004-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980005,78124NY0980005-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980006,78124NY0980006-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980007,78124NY0980007-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980008,78124NY0980008-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980009,78124NY0980009-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980010,78124NY0980010-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980011,78124NY0980011-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980012,78124NY0980012-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980013,78124NY0980013-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980014,78124NY0980014-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980015,78124NY0980015-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980016,78124NY0980016-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980017,78124NY0980017-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980018,78124NY0980018-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980019,78124NY0980019-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980020,78124NY0980020-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980021,78124NY0980021-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980022,78124NY0980022-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980023,78124NY0980023-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980024,78124NY0980024-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980025,78124NY0980025-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980026,78124NY0980026-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980027,78124NY0980027-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980028,78124NY0980028-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980029,78124NY0980029-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980030,78124NY0980030-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980031,78124NY0980031-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980032,78124NY0980032-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980049,78124NY0980049-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980050,78124NY0980050-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980051,78124NY0980051-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980052,78124NY0980052-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980053,78124NY0980053-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980054,78124NY0980054-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980055,78124NY0980055-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980056,78124NY0980056-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980057,78124NY0980057-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980058,78124NY0980058-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980059,78124NY0980059-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980060,78124NY0980060-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980061,78124NY0980061-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980062,78124NY0980062-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980063,78124NY0980063-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980064,78124NY0980064-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980065,78124NY0980065-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980066,78124NY0980066-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980067,78124NY0980067-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980068,78124NY0980068-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980069,78124NY0980069-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980070,78124NY0980070-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980071,78124NY0980071-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980072,78124NY0980072-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980073,78124NY0980073-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980074,78124NY0980074-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980075,78124NY0980075-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980076,78124NY0980076-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980077,78124NY0980077-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980078,78124NY0980078-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980079,78124NY0980079-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980080,78124NY0980080-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980129,78124NY0980129-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980130,78124NY0980130-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980131,78124NY0980131-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980132,78124NY0980132-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980133,78124NY0980133-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980134,78124NY0980134-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980135,78124NY0980135-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980136,78124NY0980136-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980137,78124NY0980137-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980138,78124NY0980138-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980139,78124NY0980139-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980140,78124NY0980140-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980141,78124NY0980141-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980142,78124NY0980142-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980143,78124NY0980143-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980144,78124NY0980144-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980145,78124NY0980145-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980146,78124NY0980146-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980147,78124NY0980147-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980148,78124NY0980148-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980149,78124NY0980149-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980150,78124NY0980150-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980151,78124NY0980151-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980152,78124NY0980152-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980153,78124NY0980153-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980154,78124NY0980154-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980155,78124NY0980155-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980156,78124NY0980156-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980157,78124NY0980157-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980158,78124NY0980158-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980159,78124NY0980159-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980160,78124NY0980160-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980161,78124NY0980161-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980162,78124NY0980162-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980163,78124NY0980163-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980164,78124NY0980164-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980165,78124NY0980165-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980166,78124NY0980166-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980167,78124NY0980167-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980168,78124NY0980168-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980169,78124NY0980169-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980170,78124NY0980170-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980171,78124NY0980171-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980172,78124NY0980172-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980173,78124NY0980173-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980174,78124NY0980174-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980175,78124NY0980175-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980176,78124NY0980176-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980177,78124NY0980177-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980178,78124NY0980178-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980179,78124NY0980179-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980180,78124NY0980180-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980181,78124NY0980181-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980182,78124NY0980182-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980183,78124NY0980183-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980184,78124NY0980184-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980185,78124NY0980185-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980186,78124NY0980186-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980187,78124NY0980187-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980188,78124NY0980188-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980189,78124NY0980189-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980190,78124NY0980190-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980191,78124NY0980191-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0980192,78124NY0980192-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990001,78124NY0990001-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990002,78124NY0990002-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990003,78124NY0990003-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990004,78124NY0990004-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990005,78124NY0990005-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990006,78124NY0990006-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990007,78124NY0990007-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990008,78124NY0990008-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990009,78124NY0990009-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990010,78124NY0990010-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990011,78124NY0990011-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990012,78124NY0990012-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990013,78124NY0990013-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990014,78124NY0990014-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990015,78124NY0990015-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990016,78124NY0990016-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990033,78124NY0990033-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990034,78124NY0990034-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990035,78124NY0990035-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990036,78124NY0990036-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990037,78124NY0990037-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990038,78124NY0990038-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990039,78124NY0990039-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990040,78124NY0990040-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990041,78124NY0990041-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990042,78124NY0990042-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990043,78124NY0990043-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990044,78124NY0990044-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990045,78124NY0990045-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990046,78124NY0990046-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990047,78124NY0990047-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990048,78124NY0990048-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990065,78124NY0990065-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990066,78124NY0990066-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990067,78124NY0990067-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990068,78124NY0990068-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990069,78124NY0990069-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990070,78124NY0990070-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990071,78124NY0990071-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990072,78124NY0990072-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990073,78124NY0990073-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990074,78124NY0990074-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990075,78124NY0990075-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990076,78124NY0990076-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990077,78124NY0990077-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990078,78124NY0990078-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990079,78124NY0990079-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990080,78124NY0990080-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990081,78124NY0990081-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990082,78124NY0990082-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990083,78124NY0990083-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990084,78124NY0990084-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990085,78124NY0990085-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990086,78124NY0990086-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990087,78124NY0990087-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990088,78124NY0990088-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990089,78124NY0990089-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990090,78124NY0990090-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990091,78124NY0990091-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990092,78124NY0990092-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990093,78124NY0990093-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990094,78124NY0990094-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990095,78124NY0990095-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990096,78124NY0990096-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990097,78124NY0990097-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990098,78124NY0990098-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990099,78124NY0990099-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990100,78124NY0990100-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990101,78124NY0990101-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990102,78124NY0990102-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990103,78124NY0990103-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990104,78124NY0990104-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990105,78124NY0990105-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990106,78124NY0990106-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990107,78124NY0990107-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990108,78124NY0990108-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990109,78124NY0990109-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990110,78124NY0990110-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990111,78124NY0990111-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990112,78124NY0990112-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990225,78124NY0990225-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990226,78124NY0990226-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990227,78124NY0990227-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990228,78124NY0990228-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990229,78124NY0990229-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990230,78124NY0990230-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990231,78124NY0990231-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990232,78124NY0990232-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990233,78124NY0990233-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990234,78124NY0990234-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990235,78124NY0990235-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990236,78124NY0990236-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990237,78124NY0990237-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990238,78124NY0990238-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990239,78124NY0990239-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990240,78124NY0990240-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990241,78124NY0990241-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990242,78124NY0990242-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990243,78124NY0990243-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990244,78124NY0990244-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990245,78124NY0990245-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990246,78124NY0990246-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990247,78124NY0990247-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990248,78124NY0990248-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990249,78124NY0990249-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990250,78124NY0990250-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990251,78124NY0990251-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990252,78124NY0990252-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990253,78124NY0990253-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990254,78124NY0990254-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990255,78124NY0990255-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990256,78124NY0990256-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990257,78124NY0990257-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990258,78124NY0990258-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990259,78124NY0990259-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990260,78124NY0990260-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990261,78124NY0990261-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990262,78124NY0990262-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990263,78124NY0990263-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990264,78124NY0990264-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990265,78124NY0990265-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990266,78124NY0990266-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990267,78124NY0990267-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990268,78124NY0990268-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990269,78124NY0990269-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990270,78124NY0990270-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990271,78124NY0990271-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990272,78124NY0990272-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990289,78124NY0990289-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990290,78124NY0990290-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990291,78124NY0990291-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990292,78124NY0990292-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990293,78124NY0990293-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990294,78124NY0990294-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990295,78124NY0990295-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990296,78124NY0990296-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990297,78124NY0990297-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990298,78124NY0990298-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990299,78124NY0990299-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990300,78124NY0990300-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990301,78124NY0990301-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990302,78124NY0990302-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990303,78124NY0990303-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990304,78124NY0990304-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990305,78124NY0990305-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990306,78124NY0990306-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990307,78124NY0990307-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990308,78124NY0990308-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990309,78124NY0990309-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990310,78124NY0990310-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990311,78124NY0990311-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990312,78124NY0990312-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990313,78124NY0990313-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990314,78124NY0990314-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990315,78124NY0990315-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990316,78124NY0990316-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990317,78124NY0990317-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990318,78124NY0990318-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990319,78124NY0990319-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY0990320,78124NY0990320-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000001,78124NY1000001-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000002,78124NY1000002-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000003,78124NY1000003-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000004,78124NY1000004-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000005,78124NY1000005-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000006,78124NY1000006-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000007,78124NY1000007-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000008,78124NY1000008-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000009,78124NY1000009-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000010,78124NY1000010-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000011,78124NY1000011-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000012,78124NY1000012-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000013,78124NY1000013-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000014,78124NY1000014-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000015,78124NY1000015-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000016,78124NY1000016-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000017,78124NY1000017-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000018,78124NY1000018-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000019,78124NY1000019-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000020,78124NY1000020-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000021,78124NY1000021-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000022,78124NY1000022-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000023,78124NY1000023-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000024,78124NY1000024-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000025,78124NY1000025-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000026,78124NY1000026-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000027,78124NY1000027-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000028,78124NY1000028-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000029,78124NY1000029-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000030,78124NY1000030-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000031,78124NY1000031-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000032,78124NY1000032-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000049,78124NY1000049-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000050,78124NY1000050-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000051,78124NY1000051-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000052,78124NY1000052-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000053,78124NY1000053-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000054,78124NY1000054-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000055,78124NY1000055-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000056,78124NY1000056-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000057,78124NY1000057-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000058,78124NY1000058-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000059,78124NY1000059-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000060,78124NY1000060-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000061,78124NY1000061-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000062,78124NY1000062-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000063,78124NY1000063-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000064,78124NY1000064-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000097,78124NY1000097-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000098,78124NY1000098-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000099,78124NY1000099-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000100,78124NY1000100-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000101,78124NY1000101-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000102,78124NY1000102-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000103,78124NY1000103-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000104,78124NY1000104-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000105,78124NY1000105-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000106,78124NY1000106-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000107,78124NY1000107-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000108,78124NY1000108-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000109,78124NY1000109-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000110,78124NY1000110-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000111,78124NY1000111-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000112,78124NY1000112-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000145,78124NY1000145-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000146,78124NY1000146-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000147,78124NY1000147-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000148,78124NY1000148-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000149,78124NY1000149-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000150,78124NY1000150-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000151,78124NY1000151-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000152,78124NY1000152-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000153,78124NY1000153-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000154,78124NY1000154-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000155,78124NY1000155-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000156,78124NY1000156-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000157,78124NY1000157-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000158,78124NY1000158-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000159,78124NY1000159-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000160,78124NY1000160-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000161,78124NY1000161-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000162,78124NY1000162-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000163,78124NY1000163-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000164,78124NY1000164-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000165,78124NY1000165-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000166,78124NY1000166-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000167,78124NY1000167-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000168,78124NY1000168-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000169,78124NY1000169-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000170,78124NY1000170-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000171,78124NY1000171-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000172,78124NY1000172-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000173,78124NY1000173-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000174,78124NY1000174-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000175,78124NY1000175-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000176,78124NY1000176-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000177,78124NY1000177-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000178,78124NY1000178-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000179,78124NY1000179-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000180,78124NY1000180-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000181,78124NY1000181-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000182,78124NY1000182-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000183,78124NY1000183-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000184,78124NY1000184-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000185,78124NY1000185-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000186,78124NY1000186-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000187,78124NY1000187-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000188,78124NY1000188-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000189,78124NY1000189-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000190,78124NY1000190-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000191,78124NY1000191-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000192,78124NY1000192-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000193,78124NY1000193-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000194,78124NY1000194-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000195,78124NY1000195-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000196,78124NY1000196-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000197,78124NY1000197-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000198,78124NY1000198-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000199,78124NY1000199-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000200,78124NY1000200-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000201,78124NY1000201-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000202,78124NY1000202-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000203,78124NY1000203-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000204,78124NY1000204-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000205,78124NY1000205-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000206,78124NY1000206-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000207,78124NY1000207-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000208,78124NY1000208-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000209,78124NY1000209-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000210,78124NY1000210-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000211,78124NY1000211-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000212,78124NY1000212-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000213,78124NY1000213-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000214,78124NY1000214-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000215,78124NY1000215-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000216,78124NY1000216-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000217,78124NY1000217-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000218,78124NY1000218-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000219,78124NY1000219-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000220,78124NY1000220-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000221,78124NY1000221-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000222,78124NY1000222-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000223,78124NY1000223-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits are available and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000224,78124NY1000224-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000225,78124NY1000225-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000226,78124NY1000226-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000227,78124NY1000227-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000228,78124NY1000228-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000229,78124NY1000229-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000230,78124NY1000230-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000231,78124NY1000231-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000232,78124NY1000232-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000233,78124NY1000233-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000234,78124NY1000234-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000235,78124NY1000235-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000236,78124NY1000236-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000237,78124NY1000237-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000238,78124NY1000238-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000239,78124NY1000239-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000240,78124NY1000240-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000241,78124NY1000241-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000242,78124NY1000242-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000243,78124NY1000243-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000244,78124NY1000244-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000245,78124NY1000245-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000246,78124NY1000246-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000247,78124NY1000247-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000248,78124NY1000248-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000249,78124NY1000249-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000250,78124NY1000250-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000251,78124NY1000251-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000252,78124NY1000252-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000253,78124NY1000253-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000254,78124NY1000254-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000255,78124NY1000255-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000256,78124NY1000256-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000257,78124NY1000257-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000258,78124NY1000258-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000259,78124NY1000259-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000260,78124NY1000260-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000261,78124NY1000261-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000262,78124NY1000262-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000263,78124NY1000263-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000264,78124NY1000264-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000265,78124NY1000265-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000266,78124NY1000266-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000267,78124NY1000267-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000268,78124NY1000268-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000269,78124NY1000269-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000270,78124NY1000270-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000271,78124NY1000271-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000272,78124NY1000272-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000273,78124NY1000273-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000274,78124NY1000274-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000275,78124NY1000275-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000276,78124NY1000276-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000277,78124NY1000277-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000278,78124NY1000278-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000279,78124NY1000279-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000280,78124NY1000280-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000281,78124NY1000281-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000282,78124NY1000282-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000283,78124NY1000283-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000284,78124NY1000284-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000285,78124NY1000285-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000286,78124NY1000286-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000287,78124NY1000287-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000288,78124NY1000288-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000289,78124NY1000289-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000290,78124NY1000290-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000291,78124NY1000291-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000292,78124NY1000292-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000293,78124NY1000293-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000294,78124NY1000294-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000295,78124NY1000295-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000296,78124NY1000296-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000297,78124NY1000297-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000298,78124NY1000298-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000299,78124NY1000299-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000300,78124NY1000300-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000301,78124NY1000301-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000302,78124NY1000302-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000303,78124NY1000303-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Gym Membership Reimbursement,,,,No,,,,,Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Design,,,,,,,,,"This plan covers services in and out of network with in-network access to 100% of local hospitals and 98% of doctors throughout 31 counties in New York State.  When you travel, BlueCard« provides access to doctors and hospitals throughout the US, Canada & Mexico. This plan does not require referrals and you do not need to identify a Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. Get paid up to $600 with our ExerciseRewards Program; a gym and fitness class reward program.  Access our free Healthy Perks program including a 24/7 Nurse Call Line and get Blue365 offers for discounts on fitness gear, weight-loss programs, dental services and more. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1000304,78124NY1000304-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020001,78124NY1020001-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020002,78124NY1020002-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020003,78124NY1020003-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020004,78124NY1020004-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020005,78124NY1020005-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020006,78124NY1020006-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020007,78124NY1020007-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020008,78124NY1020008-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020009,78124NY1020009-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020010,78124NY1020010-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020011,78124NY1020011-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020012,78124NY1020012-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020013,78124NY1020013-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020014,78124NY1020014-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020015,78124NY1020015-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020016,78124NY1020016-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020145,78124NY1020145-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020146,78124NY1020146-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020147,78124NY1020147-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020148,78124NY1020148-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020149,78124NY1020149-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020150,78124NY1020150-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020151,78124NY1020151-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020152,78124NY1020152-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020153,78124NY1020153-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020154,78124NY1020154-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020155,78124NY1020155-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020156,78124NY1020156-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020157,78124NY1020157-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020158,78124NY1020158-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020159,78124NY1020159-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020160,78124NY1020160-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020161,78124NY1020161-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020162,78124NY1020162-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020163,78124NY1020163-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020164,78124NY1020164-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020165,78124NY1020165-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020166,78124NY1020166-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020167,78124NY1020167-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020168,78124NY1020168-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020169,78124NY1020169-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020170,78124NY1020170-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020171,78124NY1020171-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020172,78124NY1020172-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020173,78124NY1020173-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020174,78124NY1020174-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020175,78124NY1020175-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020176,78124NY1020176-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020177,78124NY1020177-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020178,78124NY1020178-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020179,78124NY1020179-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020180,78124NY1020180-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020181,78124NY1020181-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020182,78124NY1020182-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020183,78124NY1020183-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020184,78124NY1020184-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020185,78124NY1020185-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020186,78124NY1020186-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020187,78124NY1020187-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020188,78124NY1020188-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020189,78124NY1020189-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020190,78124NY1020190-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020191,78124NY1020191-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020192,78124NY1020192-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020209,78124NY1020209-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020210,78124NY1020210-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020211,78124NY1020211-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020212,78124NY1020212-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020213,78124NY1020213-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020214,78124NY1020214-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020215,78124NY1020215-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020216,78124NY1020216-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020217,78124NY1020217-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020218,78124NY1020218-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020219,78124NY1020219-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020220,78124NY1020220-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020221,78124NY1020221-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020222,78124NY1020222-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020223,78124NY1020223-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020224,78124NY1020224-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020225,78124NY1020225-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020226,78124NY1020226-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020227,78124NY1020227-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020228,78124NY1020228-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020229,78124NY1020229-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020230,78124NY1020230-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020231,78124NY1020231-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020232,78124NY1020232-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020233,78124NY1020233-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020234,78124NY1020234-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020235,78124NY1020235-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020236,78124NY1020236-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020237,78124NY1020237-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020238,78124NY1020238-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020239,78124NY1020239-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1020240,78124NY1020240-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030001,78124NY1030001-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030002,78124NY1030002-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030003,78124NY1030003-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030004,78124NY1030004-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030005,78124NY1030005-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030006,78124NY1030006-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030007,78124NY1030007-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030008,78124NY1030008-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030009,78124NY1030009-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030010,78124NY1030010-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030011,78124NY1030011-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030012,78124NY1030012-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030013,78124NY1030013-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030014,78124NY1030014-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030015,78124NY1030015-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030016,78124NY1030016-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030033,78124NY1030033-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030034,78124NY1030034-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030035,78124NY1030035-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030036,78124NY1030036-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030037,78124NY1030037-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030038,78124NY1030038-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030039,78124NY1030039-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030040,78124NY1030040-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030041,78124NY1030041-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030042,78124NY1030042-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030043,78124NY1030043-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030044,78124NY1030044-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030045,78124NY1030045-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030046,78124NY1030046-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030047,78124NY1030047-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030048,78124NY1030048-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030289,78124NY1030289-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030290,78124NY1030290-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030291,78124NY1030291-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030292,78124NY1030292-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030293,78124NY1030293-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030294,78124NY1030294-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030295,78124NY1030295-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030296,78124NY1030296-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030297,78124NY1030297-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030298,78124NY1030298-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030299,78124NY1030299-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030300,78124NY1030300-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030301,78124NY1030301-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030302,78124NY1030302-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030303,78124NY1030303-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030304,78124NY1030304-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030321,78124NY1030321-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030322,78124NY1030322-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030323,78124NY1030323-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030324,78124NY1030324-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030325,78124NY1030325-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030326,78124NY1030326-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030327,78124NY1030327-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030328,78124NY1030328-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030329,78124NY1030329-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030330,78124NY1030330-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030331,78124NY1030331-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030332,78124NY1030332-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030333,78124NY1030333-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030334,78124NY1030334-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030335,78124NY1030335-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1030336,78124NY1030336-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040001,78124NY1040001-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040002,78124NY1040002-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040003,78124NY1040003-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040004,78124NY1040004-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040005,78124NY1040005-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040006,78124NY1040006-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040007,78124NY1040007-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040008,78124NY1040008-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040009,78124NY1040009-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040010,78124NY1040010-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040011,78124NY1040011-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040012,78124NY1040012-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040013,78124NY1040013-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040014,78124NY1040014-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040015,78124NY1040015-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040016,78124NY1040016-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040209,78124NY1040209-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040210,78124NY1040210-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040211,78124NY1040211-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040212,78124NY1040212-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040213,78124NY1040213-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040214,78124NY1040214-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040215,78124NY1040215-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040216,78124NY1040216-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040217,78124NY1040217-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040218,78124NY1040218-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040219,78124NY1040219-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040220,78124NY1040220-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040221,78124NY1040221-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040222,78124NY1040222-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040223,78124NY1040223-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Routine Eye Exam (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Frames & Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Contact Lenses,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits are available and preventive care is free. This plan has an embedded deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040224,78124NY1040224-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040225,78124NY1040225-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040226,78124NY1040226-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040227,78124NY1040227-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040228,78124NY1040228-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040229,78124NY1040229-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040230,78124NY1040230-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040231,78124NY1040231-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040232,78124NY1040232-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040233,78124NY1040233-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040234,78124NY1040234-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040235,78124NY1040235-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040236,78124NY1040236-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040237,78124NY1040237-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040238,78124NY1040238-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040239,78124NY1040239-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Abortion for Which Public Funding is Prohibited,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Family Planning Services,,,,,,,,,,Other Law/Regulation,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Sterilization Procedures for Men,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040240,78124NY1040240-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040243,78124NY1040243-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040245,78124NY1040245-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040245,78124NY1040245-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040245,78124NY1040245-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040245,78124NY1040245-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040245,78124NY1040245-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040245,78124NY1040245-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040245,78124NY1040245-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040245,78124NY1040245-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040245,78124NY1040245-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040245,78124NY1040245-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040245,78124NY1040245-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040245,78124NY1040245-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040245,78124NY1040245-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Dental Check-Up for Children,Yes,,,Yes,2,Visit(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Basic Dental Care - Child,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Orthodontia - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Major Dental Care - Child,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use,  accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones.   MDLIVE does not replace a members physicianłrather it is another option to receive care for acute,  non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care  or emergency room visits.  Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040241,78124NY1040241-01,Applied Behavior Analysis Based Therapies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Primary Care Visit to Treat an Injury or Illness,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Specialist Visit,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,"Outpatient Facility Fee (e.g.,  Ambulatory Surgery Center)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Outpatient Surgery Physician/Surgical Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Hospice Services,Yes,,,Yes,210,Days per Year,,,Also includes 5 visits for family bereavement counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Routine Dental Services (Adult),,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Infertility Treatment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Long-Term/Custodial Nursing Home Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Private-Duty Nursing,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Routine Eye Exam (Adult),,,,Yes,1,Exam(s) per Benefit Period,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Urgent Care Centers or Facilities,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Home Health Care Services,Yes,,,Yes,40,Visit(s) per Year,,,Each visit of up to four hours by a home health aide is one visit.,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Emergency Room Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Emergency Transportation/Ambulance,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Inpatient Physician and Surgical Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Bariatric Surgery,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Cosmetic Surgery,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Skilled Nursing Facility,Yes,,,Yes,200,Days per Year,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Prenatal and Postnatal Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Delivery and All Inpatient Services for Maternity Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Mental/Behavioral Health Outpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Mental/Behavioral Health Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Substance Abuse Disorder Outpatient Services,Yes,,,No,,,,,Also includes 20 visits per year for family counseling.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Substance Abuse Disorder Inpatient Services,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Generic Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Non-Preferred Brand Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Specialty Drugs,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Outpatient Rehabilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Habilitation Services,Yes,,,Yes,60,Visit(s) per Year,,,"Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care ProfessionalĘs office.",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Chiropractic Care,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Durable Medical Equipment,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Hearing Aids,Yes,,,No,,,,,Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,"Imaging (CT/PET Scans, MRIs)",Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Preventive Care/Screening/Immunization,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Routine Foot Care,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Acupuncture,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Weight Loss Programs,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Routine Eye Exam for Children,Yes,,,Yes,1,Exam(s) per Benefit Period,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Eye Glasses for Children,Yes,,,Yes,1,Item(s) per Benefit Period,,,One prescribed lenses and frames in a 12-month period.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Dental Check-Up for Children,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Rehabilitative Speech Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Rehabilitative Occupational and Rehabilitative Physical Therapy,Yes,,,Yes,60,Visit(s) per Year,,,60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Well Baby Visits and Care,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Laboratory Outpatient and Professional Services,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,X-rays and Diagnostic Imaging,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Basic Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Orthodontia - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Major Dental Care - Child,Yes,,,,,,,,,Dental Only Plan Available,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Basic Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Orthodontia - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Major Dental Care - Adult,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Abortion for Which Public Funding is Prohibited,,,,Yes,1,Procedure(s) per Year,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Transplant,Yes,,,No,,,,,"Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome",Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Accidental Dental,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Dialysis,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Allergy Testing,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Chemotherapy,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Radiation,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Diabetes Education,Yes,,,No,,,,,,,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Prosthetic Devices,Yes,,,No,,,,,1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices),,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Infusion Therapy,Yes,,,No,,,,,Any visits for home infusion therapy count towards your home health care visit limit.,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Treatment for Temporomandibular Joint Disorders,Yes,,,No,,,,,Covered When Medical In Nature,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Nutritional Counseling,,,,,,,,,,,,,,
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Reconstructive Surgery,Yes,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Breast Reconstructive Surgery,,,,No,,,,,,Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Family Planning Services,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Eating Disorder Treatment,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Cardiac Rehabilitation,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Assistive Communication Devices,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Sterilization Procedures for Men,,,,No,,,,,,Other Law/Regulation,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Prostate Cancer Screening,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Autologous Blood Banking,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Preadmission Testing,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Second Opinion,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Diabetic Equipment and Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Medical Supplies,,,,No,,,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Cochlear Implants,,,,No,,,,,1 per ear per time covered,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Inpatient Rehabilitation Services,,,,Yes,60,Days per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Gym Membership Reimbursement,,,,No,,,,,Up to $150 per plan year; up to an additional $150 per plan year for Spouse,Additional EHB Benefit,,,Yes,Yes
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Contact Lenses for Children,,,,Yes,1,Item(s) per Year,,,,Additional EHB Benefit,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Frames & Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Contact Lenses,,,,Yes,60,Dollars per Year,,,"$60 eyewear reimbursement per year, includes frames, lenses and contact lenses",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Design,,,,,,,,,"All Univera members have access to a Personal Assistant program offering assistance, discounts and referrals for various services to help manage your overall well-being. Each contract also includes our Dental Rewards program where you can get rewarded $150 for getting a dental cleaning and exam, in addition to our Wellness Rewards program to earn $150 for enrolling in health related programs. This plan covers services in and out of network with in network access to a large local network throughout 39 counties in New York State and does not require referrals or a designated Primary Care Physician. Telemedicine visits and adult vision benefits are available, preventive drugs are not subject to the plan deductible and preventive care is free. This plan has an aggregate deductible and out of pocket maximum.",Not EHB,,,No,No
2019,NY,78124,SERFF,1,3/4/2019 0:00,78124NY1040242,78124NY1040242-01,Telemedicine,,,,No,,,,,"Members will have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care